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General NPI Number Information
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NPI Number | 1689698490
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Entity Type | Individual
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Provider Name | PAULA M. WALLACE P.A.
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Gender | Female
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Dates
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Enumeration Date | 07/26/2006
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Last Update Date | 11/21/2016
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Provider Practice Location Address
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Address Line | 212 WALNUT ST STE 110
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City | MONROE
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State | LA
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Zip | 71201-6707
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Country | US
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Telephone | 318-323-1809
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Fax | 318-323-2668
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Provider Business Mailing Address
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Address Line | 312 GRAMMONT ST STE 404
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City | MONROE
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State | LA
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Zip | 71201-7403
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Country | US
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Telephone | 318-323-1809
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Fax | 318-323-2668
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | P.A.A10590.RX
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License Number State | LA
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