Provider Demographics
NPI:1598290249
Name:WK PELVIC & RECONSTRUCTIVE SURGERY
Entity Type:Organization
Organization Name:WK PELVIC & RECONSTRUCTIVE SURGERY
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:318-212-8780
Mailing Address - Street 1:8001 YOUREE DR
Mailing Address - Street 2:SUITE 370
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115-2302
Mailing Address - Country:US
Mailing Address - Phone:318-212-8780
Mailing Address - Fax:318-212-6752
Practice Address - Street 1:8001 YOUREE DR
Practice Address - Street 2:SUITE 370
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-2302
Practice Address - Country:US
Practice Address - Phone:318-212-8780
Practice Address - Fax:318-212-6752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-01
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2088F0040XAllopathic & Osteopathic PhysiciansUrologyFemale Pelvic Medicine and Reconstructive SurgeryGroup - Single Specialty