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NPI Code Detail

MEDICARE: CASEY L. WALLACE PT, DPT

MEDICARE: CASEY L. WALLACE PT, DPT
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
1225100000XPhysical Therapist2305207461VA

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1C05954OTHERVAGROUP MEDICARE PTAN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1134474323
Entity Type Code : Individual
Provider Name (Legal Business Name) : CASEY L. WALLACE PT, DPT
Provider Business Mailing Address
First Line : 984B LASKIN RD
Second Line :
City : VIRGINIA BEACH
State : VA
Zip : 23451-3905
Country : US
Telephone Number : 757-395-6900
Fax Number : 757-425-7180
Provider Business Practice Location Address
First Line : 984B LASKIN RD
Second Line :
City : VIRGINIA BEACH
State : VA
Zip : 23451-3905
Country : US
Telephone Number : 757-395-6900
Fax Number : 757-425-7180
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/13/2012
Last Update Date : 03/22/2021

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