MEDICARE: HOLLY CASEY WALL MD, FACS

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	2086S0122X	Plastic and Reconstructive Surgery Physician	L14095R	LA

Other Identifiers

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

General Provider Information

NPI Number	:	1245229624
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HOLLY CASEY WALL MD, FACS

Provider Business Mailing Address
First Line	:	8600 FERN AVE
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71105-5639
Country	:	US
Telephone Number	:	318-795-0801
Fax Number	:	318-795-9492

Provider Business Practice Location Address
First Line	:	8600 FERN AVE
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71105-5639
Country	:	US
Telephone Number	:	318-795-0801
Fax Number	:	318-795-9492

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

Provider Enumeration Date	:	10/18/2005
Last Update Date	:	04/09/2014

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