Healthcare Provider Details

I. General information

NPI: 1720132012
Provider Name (Legal Business Name): VICTORIA LOMAX SPECIAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 12/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 DAVID RAINES RD
SHREVEPORT LA
71107-5899
US

IV. Provider business mailing address

1625 DAVID RAINES RD
SHREVEPORT LA
71107-5899
US

V. Phone/Fax

Practice location:
  • Phone: 318-227-3348
  • Fax: 318-425-2367
Mailing address:
  • Phone: 318-227-3348
  • Fax: 318-425-2367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA06497
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.200299
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: