Provider Demographics
NPI:1366877060
Name:WALLACE, MARGARET L (PA)
Entity type:Individual
Prefix:MS
First Name:MARGARET
Middle Name:L
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:1 FORD PL STE 3A
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3450
Mailing Address - Country:US
Mailing Address - Phone:313-874-4806
Mailing Address - Fax:
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2689
Practice Address - Country:US
Practice Address - Phone:313-916-2895
Practice Address - Fax:313-916-8799
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-12
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601006812363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant