Tracy Wallace, MD

Primary specialty

Pediatrics PhysicianTaxonomy code 208000000X

License

204717 Issued in LA

Practice address

1937 S Burnside Ave
Gonzales, LA 70737-4632

Phone

(225) 765-5500

Fax

(225) 644-9286

NPI assigned

May 4, 2010

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Electronic endpoints 2

Medicare fee-for-service enrollment

Enrolled in LA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Our Lady of the Lake Physician Group LLC

  • Internal Medicine Physician
  • Baton Rouge, LA
  • NPI 1033494943

  Pediatrics

  Medicare reassignment NPD
• Our Lady of the Lake Physician Group LLC

  • Comprehensive Outpatient Rehabilitation Facility (CORF)
  • Baton Rouge, LA
  • NPI 1235912502
  NPD
• Our Lady of the Lake Physician Group LLC

  • Hematology & Oncology Physician
  • Baton Rouge, LA
  • NPI 1184671455
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1272931200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1621382400000",
    "number": "1720306558",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5959 S SHERWOOD FOREST BLVD",
            "city": "BATON ROUGE",
            "state": "LA",
            "postal_code": "708166038",
            "telephone_number": "225-765-5727",
            "fax_number": "225-765-9196"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1937 S BURNSIDE AVE",
            "city": "GONZALES",
            "state": "LA",
            "postal_code": "707374632",
            "telephone_number": "225-765-5500",
            "fax_number": "225-644-9286"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "TRACY",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2010-05-04",
        "last_updated": "2021-05-19",
        "certification_date": "2021-05-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "LA",
            "license": "204717",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2103831",
            "state": "LA"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "twallace7489@direct.casso.us.com",
            "affiliation": "N",
            "endpointDescription": "FMOLHS-Epic",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "twallace7489@direct.casso.us.com",
            "address_1": "1937 S Burnside Ave",
            "city": "Gonzales",
            "state": "LA",
            "country_code": "US",
            "postal_code": "707374632",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "endpointType": "FHIR",
            "endpointTypeDescription": "FHIR URL",
            "endpoint": "https://epicproxy.et0830.epichosted.com/FHIRProxy/api/FHIR/DSTU2/",
            "affiliation": "N",
            "endpointDescription": "FMOLHS FHIR URL",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "FHIR API",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "C-CDA",
            "address_1": "1937 S Burnside Ave",
            "city": "Gonzales",
            "state": "LA",
            "country_code": "US",
            "postal_code": "707374632",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Walgreen Co
• Walgreen Co
• Walgreen Co.
• Autumn Victoria Wallace
• Emily Paige Wallace, PT, DPT
• Marlayna P Ward
• Alexis Cecilia Washington, M.ED.
• Lisa Lynnette Weber-Curry
• Nekia M Weber, LMSW
• Ashley Aguillard Wells, PT, DPT

• Pediatrics Physician in Gonzales, LA
• Providers in Gonzales, LA by specialty
• Pediatrics Physician in Louisiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 19, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.