Cedric Charles Wallace, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

012591 Issued in NY

Practice address

20 Coolidge PL
Freeport, NY 11520-2543

Phone

(516) 779-5996

NPI assigned

Oct 3, 2008

Last updated

Apr 2, 2021By the provider in NPPES

Sex

Male

Sole proprietor

Yes

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 NY

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

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: cwallace61199@nyumc.direct-ci.com

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.

• New York University

  dba NYU Faculty Group Practice

  • Cardiovascular Disease Physician
  • Boynton Beach, FL
  • NPI 1285826438

  NY

  Medicare reassignment NPD
• Harlem Medical Associates PC

  • General Practice Physician
  • New York, NY
  • NPI 1487957692
  Medicare reassignment
• New York University

  dba NYU Langone Ambulatory Care Chelsea

  • Physical Medicine & Rehabilitation Physician
  • Boynton Beach, FL
  • NPI 1104787613
  NPD

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

{
    "created_epoch": "1222992000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1617321600000",
    "number": "1891946240",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "20 COOLIDGE PL",
            "city": "FREEPORT",
            "state": "NY",
            "postal_code": "115202543",
            "telephone_number": "516-779-5996"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "20 COOLIDGE PL",
            "city": "FREEPORT",
            "state": "NY",
            "postal_code": "115202543",
            "telephone_number": "516-779-5996"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "CEDRIC",
        "middle_name": "CHARLES",
        "name_prefix": "Mr.",
        "credential": "PA-C",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2008-10-03",
        "last_updated": "2021-04-02",
        "certification_date": "2021-04-02",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NY",
            "license": "012591",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "cwallace61199@nyumc.direct-ci.com",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "address_1": "20 Coolidge Pl",
            "city": "Freeport",
            "state": "NY",
            "country_code": "US",
            "postal_code": "115202543",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Vituity- New York Medical Group PLLC
• Marian Viviano, LCSW
• Diane Wade
• Nicole Walcott, LMHC
• Walgreen Eastern Co Inc (Walgreens #04845)
• Carolyn Walsh, MSW
• Walter E. Mendoza Chiropractor, P.C
• Regine Walton, L.P.N.
• Miriam Warren, RN
• Tatiana Webb, RN

• Physician Assistant in Freeport, NY
• Providers in Freeport, NY by specialty
• Physician Assistant in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 2, 2021; 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.