Healthcare Provider Details

I. General information

NPI: 1598290249
Provider Name (Legal Business Name): WK PELVIC & RECONSTRUCTIVE SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2017
Last Update Date: 05/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8001 YOUREE DR SUITE 370
SHREVEPORT LA
71115-2302
US

IV. Provider business mailing address

8001 YOUREE DR SUITE 370
SHREVEPORT LA
71115-2302
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-8780
  • Fax: 318-212-6752
Mailing address:
  • Phone: 318-212-8780
  • Fax: 318-212-6752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088F0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Urology) Physician
License Number
License Number State

VIII. Authorized Official

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