Healthcare Provider Details

I. General information

NPI: 1689698490
Provider Name (Legal Business Name): PAULA M. WALLACE P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 11/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 WALNUT ST STE 110
MONROE LA
71201-6707
US

IV. Provider business mailing address

312 GRAMMONT ST STE 404
MONROE LA
71201-7403
US

V. Phone/Fax

Practice location:
  • Phone: 318-323-1809
  • Fax: 318-323-2668
Mailing address:
  • Phone: 318-323-1809
  • Fax: 318-323-2668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberP.A.A10590.RX
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: