Provider Demographics
NPI:1679169783
Name:TORBERT, WALLACE HENRY III (PA-C)
Entity type:Individual
Prefix:MR
First Name:WALLACE
Middle Name:HENRY
Last Name:TORBERT
Suffix:III
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4305 LINDA DR
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36867-1615
Mailing Address - Country:US
Mailing Address - Phone:706-570-8101
Mailing Address - Fax:
Practice Address - Street 1:2000 16TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1600
Practice Address - Country:US
Practice Address - Phone:706-320-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-14
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA101520363A00000X
GA010232363A00000X
FLPA9116491363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant