Provider Demographics
NPI:1376910240
Name:WK PEDIATRIC PULMONOLOGY SPECIALISTS
Entity Type:Organization
Organization Name:WK PEDIATRIC PULMONOLOGY SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NETWORK ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:J
Authorized Official - Last Name:GAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-212-5780
Mailing Address - Street 1:2530 BERT KOUN LOOP
Mailing Address - Street 2:SUITE 114
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3132
Mailing Address - Country:US
Mailing Address - Phone:318-212-5781
Mailing Address - Fax:318-212-5785
Practice Address - Street 1:2530 BERT KOUN LOOP
Practice Address - Street 2:SUITE 114
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3132
Practice Address - Country:US
Practice Address - Phone:318-212-5781
Practice Address - Fax:318-212-5785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-27
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric PulmonologyGroup - Single Specialty