Healthcare Provider Details

I. General information

NPI: 1528307238
Provider Name (Legal Business Name): WK TRANSPLANT PHYSICIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2013
Last Update Date: 02/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2751 ALBERT L BICKNELL DR 4TH FLOOR
SHREVEPORT LA
71103-3920
US

IV. Provider business mailing address

2751 ALBERT L BICKNELL DR 4TH FLOOR
SHREVEPORT LA
71103-3920
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-4275
  • Fax: 318-212-4555
Mailing address:
  • Phone: 318-212-4275
  • Fax: 318-212-4555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: GREG J GAVIN
Title or Position: NETWORK ADMINISTRATOR
Credential:
Phone: 318-212-4232