Healthcare Provider Details

I. General information

NPI: 1295598043
Provider Name (Legal Business Name): JOHN WALLI NPC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2024
Last Update Date: 02/05/2024
Certification Date: 02/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2781 C T SWITZER SR DR
BILOXI MS
39531-4536
US

IV. Provider business mailing address

16443 DELIA DR
BILOXI MS
39532-9411
US

V. Phone/Fax

Practice location:
  • Phone: 228-594-2900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: JOHN WALLI
Title or Position: NP-C
Credential:
Phone: 228-860-5164