Phillip Tyler Wallace, APRN

Primary specialty

Nurse PractitionerTaxonomy code 363L00000X

License

APRN11003275 Issued in FL

Practice address

4500 San Pablo Rd S
Jacksonville, FL 32224-1865

Phone

(904) 953-2000

NPI assigned

Sep 6, 2019

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in FL

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

Specialty

Nurse Practitioner

Education

Other, 2019

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Mayo Clinic JacksonvilleGroup PAC ID 5698689297, 1,595 clinicians

Practice addresses (Care Compare)

Merit-based Incentive Payment System (MIPS)

Final score

91.86 of 100Reported as group

Quality

85.7

Promoting interoperability

100

Improvement activities

40

Cost

78.45

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

State licenses

Practice roles

Locations

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.

• Mayo Clinic Jacksonville

  • Multi-Specialty Clinic/Center
  • Jacksonville, FL
  • NPI 1790772317
  Medicare reassignment Care Compare group
• Respiratory Critical Care and Sleep Medicine Associates,Inc

  • Pulmonary Disease Physician
  • Jacksonville, FL
  • NPI 1386622629
  Medicare reassignment NPD

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

{
    "created_epoch": "1567728000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1781049600000",
    "number": "1821647447",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 860912",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "554860912",
            "fax_number": "904-253-6964"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4500 SAN PABLO RD S",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322241865",
            "telephone_number": "904-953-2000"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1325 San Marco Blvd Ste 300",
            "address_purpose": "LOCATION",
            "city": "Jacksonville",
            "state": "FL",
            "postal_code": "322078567",
            "country_code": "US",
            "telephone_number": "904-253-6910",
            "fax_number": "904-253-6964",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "PHILLIP",
        "middle_name": "TYLER",
        "credential": "APRN",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2019-09-06",
        "last_updated": "2026-06-10",
        "certification_date": "2026-06-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "FL",
            "license": "APRN11003275",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "pwallace2697033@ehrdirect.mayoclinicmsg.org",
            "affiliation": "N",
            "address_1": "4500 San Pablo Rd S",
            "city": "Jacksonville",
            "state": "FL",
            "country_code": "US",
            "postal_code": "322241865",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Marquita Wallace, PHARMD, RPH
• Michael Wallace, MD
• Moira Petirs Wallace, M.D.
• Nicholas James Wallace, DMD
• Patricia J Wallace, ARNP-BC
• Ricky Wallace
• Shanthalitta Seals Wallace, LMHC
• Taylor K Wallace, CNA
• Terrica Diane Wallace, PHARMD.
• Max Joseph Wallack

• Nurse Practitioner in Jacksonville, FL
• Providers in Jacksonville, FL by specialty
• Nurse Practitioner in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 10, 2026; 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.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.