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General NPI Number Information
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NPI Number | 1598290249
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Entity Type | Organization
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Legal Business Name | WK PELVIC & RECONSTRUCTIVE SURGERY
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Dates
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Enumeration Date | 05/01/2017
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Last Update Date | 05/01/2017
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Provider Practice Location Address
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Address Line | 8001 YOUREE DR SUITE 370
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City | SHREVEPORT
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State | LA
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Zip | 71115-2302
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Country | US
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Telephone | 318-212-8780
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Fax | 318-212-6752
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Provider Business Mailing Address
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Address Line | 8001 YOUREE DR SUITE 370
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City | SHREVEPORT
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State | LA
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Zip | 71115-2302
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Country | US
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Telephone | 318-212-8780
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Fax | 318-212-6752
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Authorized Official
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Title or Position | NETWORK ADMINISTRATOR
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Name | GREG J GAVIN
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Credential |
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Telephone | 318-212-8780
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2088F0040X
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Taxonomy Name | Urogynecology and Reconstructive Pelvic Surgery (Urology) Physician
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License Number |
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License Number State |
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