Kacie Wallace, M.S., PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

1151843 Issued in MI

Practice address

22101 Moross Rd
Detroit, MI 48236-2148

Phone

(313) 343-4000

NPI assigned

May 17, 2018

Sex

Female

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in MI

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

Master of Science, Physician Assistant

State licenses

Practice roles

Interoperability endpoints

• Direct secure messaging: kwallace1156912@direct.hfhs.org

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

• Emergency Department Physicians, P.C.

  • Emergency Medicine Physician
  • Detroit, MI
  • NPI 1225083595
  Medicare reassignment
• Independent Emergency Physicians, P.C.

  • Emergency Medical Services (Emergency Medicine) Physician
  • Southfield, MI
  • NPI 1780791343
  Medicare reassignment
• Independent Observation Physicians PLLC

  • Emergency Medical Services (Emergency Medicine) Physician
  • Southfield, MI
  • NPI 1700119500
  Medicare reassignment
• Observation Emergency Physicians, P.C.

  • Emergency Medicine Physician
  • Detroit, MI
  • NPI 1497920524
  Medicare reassignment
• Orchardview Physicians

  • Urgent Care Clinic/Center
  • Washington Township, MI
  • NPI 1649435256
  NPD (past)

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

{
    "created_epoch": "1526515200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1568505600000",
    "number": "1750871455",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "226 WIMPOLE DR",
            "city": "ROCHESTER HILLS",
            "state": "MI",
            "postal_code": "483092148",
            "telephone_number": "248-720-8197"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "22101 MOROSS RD",
            "city": "DETROIT",
            "state": "MI",
            "postal_code": "482362148",
            "telephone_number": "313-343-4000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "KACIE",
        "credential": "M.S., PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2018-05-17",
        "last_updated": "2019-09-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "MI",
            "license": "1151843",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Dajuawn Wallace
• Denise Elizabeth Wallace, MA, LLP
• Inga Yvette Wallace
• Jaclyn Ann Wallace
• Jarred E Wallace, RN
• Kelsey Wallace, LMT
• Margaret L Wallace, PA
• Mercedes Wallace
• Priscilla Wallace
• Robert Jason Wallace, ATC

• Physician Assistant in Detroit, MI
• Providers in Detroit, MI by specialty
• Physician Assistant in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 15, 2019; 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.