William Jacob Wallace, PA

Primary specialty

Surgical Physician AssistantTaxonomy code 363AS0400X

License

PA2743 Issued in TN

Practice address

105 S Willow Ave
Cookeville, TN 38501-4667

Phone

(931) 372-7716

Fax

(931) 372-0087

NPI assigned

May 16, 2015

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 2

Addresses

Other identifiers 1

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in TN

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

Physician Assistant

Education

Other, 2014

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Campbell Clinic, PCGroup PAC ID 9638082076, 229 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Cookeville Regional Medical Center Hospital, Cookeville, TN, CCN 440059

Merit-based Incentive Payment System (MIPS)

Final score

75.09 of 100Reported as group

Quality

50.47

Promoting interoperability

99

Improvement activities

40

Cost

67.33

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: wwallace@t1ortho.gwaydirect.com
• Direct secure messaging: william.wallace.1@1366.direct.athenahealth.com
• FHIR API: https://api.platform.athenahealth.com/14704/brand/1/csg/1/fhir/r4
• FHIR API: https://api.platform.athenahealth.com/1366/brand/1/csg/1/fhir/r4

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.

• Campbell Clinic, PC

  • Orthopaedic Surgery Physician
  • Germantown, TN
  • NPI 1003835141
  Medicare reassignment Care Compare group
• Campbell Clinic PC

  • Durable Medical Equipment & Medical Supplies
  • Carthage, TN
  • NPI 1669366068
  NPD
• Titan Orthopedics of Memphis, PLLC

  • Orthopaedic Surgery Physician
  • Memphis, TN
  • NPI 1013463694
  NPD
• Campbell Clinic

  • Magnetic Resonance Imaging (MRI) Clinic/Center
  • Germantown, TN
  • NPI 1588619944
  NPD (past)

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• Cookeville Regional Medical Center

  • General Acute Care Hospital
  • Cookeville, TN
  • NPI 1275531956
  Care Compare affiliation

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

{
    "created_epoch": "1431734400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1598486400000",
    "number": "1992183412",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "203 N CEDAR AVE",
            "city": "COOKEVILLE",
            "state": "TN",
            "postal_code": "385012498",
            "telephone_number": "931-528-1992",
            "fax_number": "931-526-4381"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "105 S WILLOW AVE",
            "city": "COOKEVILLE",
            "state": "TN",
            "postal_code": "385014667",
            "telephone_number": "931-372-7716",
            "fax_number": "931-372-0087"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "150 Sam Walton Dr",
            "address_2": "#600",
            "address_purpose": "LOCATION",
            "city": "Sparta",
            "state": "TN",
            "postal_code": "385838815",
            "country_code": "US",
            "telephone_number": "931-739-4000",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "203 N Cedar Ave",
            "address_purpose": "LOCATION",
            "city": "Cookeville",
            "state": "TN",
            "postal_code": "38501",
            "country_code": "US",
            "telephone_number": "931-528-1992 x114",
            "fax_number": "931-526-4381",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "WILLIAM",
        "middle_name": "JACOB",
        "credential": "PA",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2015-05-16",
        "last_updated": "2020-08-27",
        "certification_date": "2020-08-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "TN",
            "license": "2743",
            "primary": false
        },
        {
            "code": "363AS0400X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Surgical",
            "state": "TN",
            "license": "PA2743",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "Q015216",
            "state": "TN"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "wwallace@t1ortho.gwaydirect.com",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "CSV",
            "contentTypeDescription": "CSV",
            "address_1": "105 S Willow Ave",
            "city": "Cookeville",
            "state": "TN",
            "country_code": "US",
            "postal_code": "385014667",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Emily Claire Coleman Walker, FNP
• Kristin Steele Walker, BEHAVIOR TECHNICAN
• Emily Wallace
• Eric Lee Wallace, M.D.
• Natalie N Wallace
• Amy Catherine Ward, BS
• Tiffany Ward, FNP
• Washington Ave Family Practice
• William Walter Wassynger, M.D.
• Mark Wathen, MD

• Surgical Physician Assistant in Cookeville, TN
• Providers in Cookeville, TN by specialty
• Surgical Physician Assistant in Tennessee

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 27, 2020; 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.