Wallace Edwin Wilson, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

4053 Issued in GA

Practice address

410 Peachtree Pkwy Ste 300
Cumming, GA 30041-7407

Phone

(404) 255-1933

Fax

(404) 785-2822

NPI assigned

Jan 12, 2006

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

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

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.

• Children's Orthopaedics of Atlanta P.C.

  • Orthopaedic Surgery Physician
  • Atlanta, GA
  • NPI 1548247000
  NPD (past)
• Choa Hospital Based, LLC

  • Pediatrics Physician
  • Brookhaven, GA
  • NPI 1457695488
  NPD (past)

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

{
    "created_epoch": "1137024000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1654473600000",
    "number": "1841279411",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "410 PEACHTREE PKWY STE 300",
            "city": "CUMMING",
            "state": "GA",
            "postal_code": "300417407",
            "telephone_number": "404-255-1933",
            "fax_number": "404-785-2822"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "410 PEACHTREE PKWY STE 300",
            "city": "CUMMING",
            "state": "GA",
            "postal_code": "300417407",
            "telephone_number": "404-255-1933",
            "fax_number": "404-785-2822"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WILSON",
        "first_name": "WALLACE",
        "middle_name": "EDWIN",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-01-12",
        "last_updated": "2022-06-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "GA",
            "license": "4053",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "choa@choa.gadirect.net",
            "affiliation": "N",
            "address_1": "410 Peachtree Pkwy Ste 300",
            "city": "Cumming",
            "state": "GA",
            "country_code": "US",
            "postal_code": "300417407",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Constance Wilson-Springer
• Britain Pruitt Wilson, O.T.R./L.
• Esleen Wilson
• Gretchen M Wilson
• Veronica Dmitriya Wilson, MA, CCC-SLP
• William Marshall Wilson, NP
• Windermere Dental, P.C.
• Lara Leigh Windom, LPN
• Mark D Winokur, M.D.
• Kelly Dean Winter, CP, LP

• Physician Assistant in Cumming, GA
• Providers in Cumming, GA by specialty
• Physician Assistant in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 6, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.