Healthcare Provider Details

I. General information

NPI: 1760043491
Provider Name (Legal Business Name): WK PREFERRED PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2019
Last Update Date: 06/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 HOSPITAL DR STE 120
BOSSIER CITY LA
71111-2193
US

IV. Provider business mailing address

1202 LOUISIANA AVE
SHREVEPORT LA
71101-3910
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-7982
  • Fax: 318-212-7989
Mailing address:
  • Phone: 318-212-8951
  • Fax: 318-212-6752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW WHEELER
Title or Position: REVENUE CONTRACT MANAGER
Credential:
Phone: 318-212-8299