MEDICARE: NOLAN WALLACE

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	225100000X	Physical Therapist	4484	NE

General Provider Information

NPI Number	:	1043903107
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NOLAN WALLACE

Provider Business Mailing Address
First Line	:	114 E 1ST ST STE 105
Second Line	:
City	:	PAPILLION
State	:	NE
Zip	:	68046-2407
Country	:	US
Telephone Number	:	402-933-2010
Fax Number	:

Provider Business Practice Location Address
First Line	:	114 E 1ST ST STE 105
Second Line	:
City	:	PAPILLION
State	:	NE
Zip	:	68046-2407
Country	:	US
Telephone Number	:	402-933-2010
Fax Number	:

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

Provider Enumeration Date	:	06/02/2023
Last Update Date	:	06/02/2023

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Directions to “ NOLAN WALLACE ” Practice Location

Language	Start Address	Practice Location

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