Provider Demographics
NPI:1487681730
Name:MOSES, WENDY MCBRIDE (MD)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:MCBRIDE
Last Name:MOSES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 LOUISIANA AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-3910
Mailing Address - Country:US
Mailing Address - Phone:318-212-8951
Mailing Address - Fax:318-212-6752
Practice Address - Street 1:1811 E BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:SUITE 400
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5740
Practice Address - Country:US
Practice Address - Phone:318-212-3810
Practice Address - Fax:318-212-3815
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022307207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1495115Medicaid
LA5Y473CY14Medicare PIN
G50901Medicare UPIN
LA1495115Medicaid
LA5Y473CE45Medicare PIN