Provider Demographics
NPI:1053539783
Name:WALLACE, JAMES EDWARD JR (PA-C)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:EDWARD
Last Name:WALLACE
Suffix:JR
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:101 W UNIVERSITY AVE
Mailing Address - Street 2:SPINE AND PAIN MANAGEMENT
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3909
Mailing Address - Country:US
Mailing Address - Phone:217-366-1326
Mailing Address - Fax:217-366-6106
Practice Address - Street 1:101 W UNIVERSITY AVE
Practice Address - Street 2:SPINE AND PAIN MANAGEMENT
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3909
Practice Address - Country:US
Practice Address - Phone:217-366-8796
Practice Address - Fax:217-366-6106
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2013-09-24
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Provider Licenses
StateLicense IDTaxonomies
IL85000087363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL590860Medicare ID - Type Unspecified
IL0533210001Medicare NSC
P11543Medicare UPIN