MEDICARE: W PROFESSIONAL SURGICAL SERVICES PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207YX0007X	Plastic Surgery within the Head & Neck (Otolaryngology) Physician

General Provider Information

NPI Number	:	1861205379
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	W PROFESSIONAL SURGICAL SERVICES PLLC

Provider Business Mailing Address
First Line	:	6608 N WESTERN AVE # 416
Second Line	:
City	:	NICHOLS HILLS
State	:	OK
Zip	:	73116-7326
Country	:	US
Telephone Number	:	405-748-5950
Fax Number	:	405-607-3580

Provider Business Practice Location Address
First Line	:	10001 BROADWAY EXT STE A
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73114-6307
Country	:	US
Telephone Number	:	405-748-5950
Fax Number	:	405-607-3580

Authorized Official
Title or Position	:	PHYSICIAN & OWNER
Name	:	IVAN WAYNE
Credential	:	MD
Telephone Number	:	405-748-5950

Provider Enumeration Date	:	01/29/2025
Last Update Date	:	01/30/2025

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