Healthcare Provider Details

I. General information

NPI: 1538200381
Provider Name (Legal Business Name): GARY LANE WEASE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S. ARKANSAS STREET
LEESVILLE LA
71446
US

IV. Provider business mailing address

1020 W FERTITTA BLVD
LEESVILLE LA
71446-4645
US

V. Phone/Fax

Practice location:
  • Phone: 337-239-7227
  • Fax: 337-238-4922
Mailing address:
  • Phone: 337-419-0735
  • Fax: 337-238-5089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number339940
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number339940
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: