Provider Demographics
NPI:1780470641
Name:WALLOW, CARSYN
Entity type:Individual
Prefix:
First Name:CARSYN
Middle Name:
Last Name:WALLOW
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 MINNESOTA AVE
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70062-6156
Mailing Address - Country:US
Mailing Address - Phone:504-487-0690
Mailing Address - Fax:504-487-0690
Practice Address - Street 1:111 ACADIA PARK DR
Practice Address - Street 2:
Practice Address - City:RACELAND
Practice Address - State:LA
Practice Address - Zip Code:70394-2619
Practice Address - Country:US
Practice Address - Phone:985-537-7575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-17
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant