Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0122X | Plastic and Reconstructive Surgery | L14095R | LA |
NPI | 1245229624 |
---|---|
Provider Name | Holly Casey Wall |
First Address | Shreveport, LA 71105-5639 |
Second Address | Shreveport, LA 71105-5639 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/10/2005 |
Last Update Date | 09/04/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1184306 | (05) | LA |
H00324 | (02) |