Healthcare Provider Details

I. General information

NPI: 1285346932
Provider Name (Legal Business Name): WK VASCULAR SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2022
Last Update Date: 12/14/2022
Certification Date: 12/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2551 GREENWOOD RD STE 230
SHREVEPORT LA
71103-3985
US

IV. Provider business mailing address

2551 GREENWOOD RD STE 230
SHREVEPORT LA
71103-3985
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-8177
  • Fax: 318-212-8179
Mailing address:
  • Phone: 318-212-8177
  • Fax: 318-212-8179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

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