Provider Demographics
NPI:1689698490
Name:WALLACE, PAULA M (PA)
Entity Type:Individual
Prefix:MS
First Name:PAULA
Middle Name:M
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:312 GRAMMONT ST STE 404
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-7403
Mailing Address - Country:US
Mailing Address - Phone:318-323-1809
Mailing Address - Fax:318-323-2668
Practice Address - Street 1:212 WALNUT ST
Practice Address - Street 2:STE 110
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-6707
Practice Address - Country:US
Practice Address - Phone:318-323-1809
Practice Address - Fax:318-323-2668
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAP.A.A10590.RX363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1429112Medicaid
LA1429112Medicaid
LA5CE50P516Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER