Healthcare Provider Details

I. General information

NPI: 1861860629
Provider Name (Legal Business Name): WK PREMIER PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2015
Last Update Date: 09/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 HOSPITAL DR SUITE 420
BOSSIER CITY LA
71111-2394
US

IV. Provider business mailing address

2300 HOSPITAL DR SUITE 420
BOSSIER CITY LA
71111-2394
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-7880
  • Fax: 318-212-7978
Mailing address:
  • Phone: 318-212-7880
  • Fax: 318-212-7978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: GREG J GAVIN
Title or Position: NETWORK ADMINISTRATOR
Credential:
Phone: 318-212-8780