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General NPI Number Information
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NPI Number | 1396945234
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Entity Type | Organization
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Legal Business Name | WALLIS DERMATOLOGY ASSOCIATES PLLC
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Dates
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Enumeration Date | 07/19/2007
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Last Update Date | 02/13/2026
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Provider Practice Location Address
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Address Line | 3535 N FOURTH ST STE 400
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City | LONGVIEW
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State | TX
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Zip | 75605-0038
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Country | US
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Telephone | 903-757-3881
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Fax | 903-757-5948
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Provider Business Mailing Address
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Address Line | 3535 N FOURTH ST STE 400
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City | LONGVIEW
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State | TX
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Zip | 75605-0038
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Country | US
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Telephone | 903-757-3881
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Fax | 903-757-5948
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Authorized Official
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Title or Position | CREDENTIALING OFFICER
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Name | ELIZABETH BOWEN
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Credential |
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Telephone | 903-503-7330
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | H6685
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License Number State | TX
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