Healthcare Provider Details

I. General information

NPI: 1174959779
Provider Name (Legal Business Name): KENDALL THOMAS PILGREEN P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2013
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 LINE AVE 3RD FLOOR TOWER 2
SHREVEPORT LA
71101
US

IV. Provider business mailing address

1202 LOUISIANA AVE
SHREVEPORT LA
71101-3910
US

V. Phone/Fax

Practice location:
  • Phone: 318-716-4610
  • Fax: 318-716-4690
Mailing address:
  • Phone: 318-212-8574
  • Fax: 318-212-4153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.200647
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: