Healthcare Provider Details

I. General information

NPI: 1497141311
Provider Name (Legal Business Name): PELICAN STATE FOOT & ANKLE CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2015
Last Update Date: 07/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1938 JACKSON ST
ALEXANDRIA LA
71301-6437
US

IV. Provider business mailing address

PO BOX 1228
ALEXANDRIA LA
71309-1228
US

V. Phone/Fax

Practice location:
  • Phone: 985-867-0301
  • Fax:
Mailing address:
  • Phone: 985-867-0301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberDPM.200036
License Number StateLA

VIII. Authorized Official

Name: DR. JON M WILSON JR.
Title or Position: OWNER
Credential: DPM
Phone: 985-867-0301