Healthcare Provider Details

I. General information

NPI: 1124492137
Provider Name (Legal Business Name): WESLEY COLEMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2015
Last Update Date: 11/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 YORKTOWN DR
ALEXANDRIA LA
71303-3621
US

IV. Provider business mailing address

1200 S FARMERVILLE ST
RUSTON LA
71270-5941
US

V. Phone/Fax

Practice location:
  • Phone: 318-445-8380
  • Fax: 318-445-9753
Mailing address:
  • Phone: 318-445-8380
  • Fax: 318-445-9753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA300402
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: