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NPI Code Detail

MEDICARE: MR. BILLY MICHEAL WALLACE III

MEDICARE: MR. BILLY MICHEAL WALLACE III
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
1163W00000XRegistered Nurse210380LA

General Provider Information

NPI Number : 1194656454
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. BILLY MICHEAL WALLACE III
Provider Business Mailing Address
First Line : 4921 TRENTON ST
Second Line :
City : METAIRIE
State : LA
Zip : 70006-6419
Country : US
Telephone Number : 504-738-4023
Fax Number :
Provider Business Practice Location Address
First Line : 1401 FOUCHER ST
Second Line :
City : NEW ORLEANS
State : LA
Zip : 70115-3593
Country : US
Telephone Number : 504-897-7011
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/26/2026
Last Update Date : 05/26/2026

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