MEDICARE: LAUREN MARIE WALLACE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1528926631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAUREN MARIE WALLACE PA-C

Provider Business Mailing Address
First Line	:	441 POINT PLACE RD
Second Line	:
City	:	DOWNSVILLE
State	:	LA
Zip	:	71234-5807
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5400 E TEXAS ST
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-6906
Country	:	US
Telephone Number	:	318-675-1313
Fax Number	:	888-965-0619

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/15/2026
Last Update Date	:	03/13/2026

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