Connie Sue Wallace, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

102472 Issued in NC

Practice address

10030 Gilead Rd Ste 201
Huntersville, NC 28078-7545

Phone

(704) 887-4530

Fax

(704) 887-4531

NPI assigned

Jun 5, 2007

Last updated

Aug 23, 2022By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 3

Electronic endpoints 2

Medicare fee-for-service enrollment

Enrolled in NC

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: cwallace159078@direct.novanthealth.org

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Curana Health of North Carolina PLLC

  • Internal Medicine Physician
  • Durham, NC
  • NPI 1770217176
  Medicare reassignment
• Novant Health Medical Group, LLC

  dba Novant Health Pediatric Neurology & Sleep

  • Neurology with Special Qualifications in Child Neurology Physician
  • Charlotte, NC
  • NPI 1366409492
  Medicare reassignment
• Physicians Eldercare PA

  • General Practice Physician
  • Durham, NC
  • NPI 1023083268
  Medicare reassignment
• The Presbyterian Hospital

  dba Novant Health Senior Care

  • Geriatric Medicine (Internal Medicine) Physician
  • Charlotte, NC
  • NPI 1053365817
  Medicare reassignment
• Novant Health Medical Group, LLC

  dba Novant Health Dermatology

  • Dermatology Physician
  • Charlotte, NC
  • NPI 1205481009
  NPD
• Novant Health Medical Group, LLC

  dba Novant Health Elizabeth OB/GYN

  • Obstetrics & Gynecology Physician
  • Matthews, NC
  • NPI 1386506137
  NPD
• Novant Medical Group Inc

  dba Novant Health Uptown Primary Care

  • Internal Medicine Physician
  • Charlotte, NC
  • NPI 1841610292
  NPD
• The Presbyterian Hospital

  dba Novant Health Heart and Vascular Institute

  • Cardiovascular Disease Physician
  • Charlotte, NC
  • NPI 1457695264
  NPD
• The Presbyterian Hospital

  dba Novant Health Infusion

  • Internal Medicine Physician
  • Charlotte, NC
  • NPI 1740169820
  NPD
• Revelstone Family Practice

  • Family Medicine Physician
  • Albemarle, NC
  • NPI 1790143436
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1181001600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1661212800000",
    "number": "1619179132",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 60447",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282600447",
            "telephone_number": "704-384-5043",
            "fax_number": "704-384-8895"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "10030 GILEAD RD STE 201",
            "city": "HUNTERSVILLE",
            "state": "NC",
            "postal_code": "280787545",
            "telephone_number": "704-887-4530",
            "fax_number": "704-887-4531"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "125 Queens Rd Ste 330",
            "address_purpose": "LOCATION",
            "city": "Charlotte",
            "state": "NC",
            "postal_code": "282043215",
            "country_code": "US",
            "telephone_number": "704-384-5043",
            "fax_number": "704-384-8895",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "CONNIE",
        "middle_name": "SUE",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2007-06-05",
        "last_updated": "2022-08-23",
        "certification_date": "2022-08-23",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NC",
            "license": "102472",
            "primary": true
        },
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "NC",
            "license": "102472",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "159XJ",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8101076",
            "state": "NC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PTAN",
            "identifier": "2747736E",
            "state": "NC"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "cwallace159078@direct.novanthealth.org",
            "affiliation": "N",
            "address_1": "125 Baldwin Ave Ste 200",
            "city": "Charlotte",
            "state": "NC",
            "country_code": "US",
            "postal_code": "282043370",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "cwallace159078@direct.novanthealth.org",
            "affiliation": "N",
            "address_1": "125 Queens Rd Ste 330",
            "city": "Charlotte",
            "state": "NC",
            "country_code": "US",
            "postal_code": "282043215",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Walgreen Co (Walgreens #11424)
• Walgreen Co. (Walgreens #10287)
• Brandi Allison Walker
• Mesha Harris Walker, M.S.
• Michael Walker
• David Langdon Walrath, MD
• Destiny Deonna Walters, PA
• Lauren Walters
• Nicole Walton
• Warby Parker Inc.

• Physician Assistant in Huntersville, NC
• Providers in Huntersville, NC by specialty
• Physician Assistant in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 23, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.