Provider Demographics
NPI:1679068092
Name:WALLACE-SHAW, KASIA LAYNE (MD)
Entity type:Individual
Prefix:
First Name:KASIA
Middle Name:LAYNE
Last Name:WALLACE-SHAW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KASIA
Other - Middle Name:LAYNE
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1137
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32902-1137
Mailing Address - Country:US
Mailing Address - Phone:321-952-9696
Mailing Address - Fax:321-952-7937
Practice Address - Street 1:5270 BABCOCK ST NE STE 1
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-4616
Practice Address - Country:US
Practice Address - Phone:321-241-6800
Practice Address - Fax:321-241-6890
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME148403208000000X, 208000000X
FL27310390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program