Basic Information
| Provider Information | |||||||||
| NPI: | 1679068092 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE-SHAW | ||||||||
| FirstName: | KASIA | ||||||||
| MiddleName: | LAYNE | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | WALLACE | ||||||||
| OtherFirstName: | KASIA | ||||||||
| OtherMiddleName: | LAYNE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1600 S ANDREWS AVE | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333162510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543554400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1651 N SEMORAN BLVD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328073575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072491234 | ||||||||
| FaxNumber: | 4072491755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2018 | ||||||||
| LastUpdateDate: | 06/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 27310 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | 390200000X | 27310 | FL | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | ME148403 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.