Individual
MICHAEL WALLIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
NP
Contact information
Practice address
1634 ELTON RD, JENNINGS, LA 70546-3614
(800) 893-9698
Mailing address
200 CORPORATE BLVD, SUITE 201, LAFAYETTE, LA 70508-3870
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
RN112816
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2356003
—
LA
Enumeration date
03/10/2014
Last updated
01/26/2020
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