Healthcare Provider Details

I. General information

NPI: 1295435337
Provider Name (Legal Business Name): WK FAMILY MEDICINE RUSTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2023
Last Update Date: 03/07/2023
Certification Date: 03/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2916 N TRENTON ST
RUSTON LA
71270-2444
US

IV. Provider business mailing address

2916 N TRENTON ST
RUSTON LA
71270-2444
US

V. Phone/Fax

Practice location:
  • Phone: 318-254-2892
  • Fax: 318-635-9857
Mailing address:
  • Phone: 318-254-2892
  • Fax: 318-635-9857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MARY J WARD
Title or Position: SR. VP FINANCE
Credential:
Phone: 318-716-4939