Provider Demographics
NPI:1881459667
Name:WALLACE, MAURA KATHLEEN (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:MAURA
Middle Name:KATHLEEN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:874 PROPRIETORS RD
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-3152
Mailing Address - Country:US
Mailing Address - Phone:614-885-9405
Mailing Address - Fax:614-885-9481
Practice Address - Street 1:874 PROPRIETORS RD
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-3152
Practice Address - Country:US
Practice Address - Phone:614-885-9405
Practice Address - Fax:614-885-9481
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-20
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH50.008630363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical