Provider Demographics
NPI:1801959929
Name:ROLAND S. WAGUESPACK MD APMC
Entity type:Organization
Organization Name:ROLAND S. WAGUESPACK MD APMC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:ROLAND
Authorized Official - Middle Name:S
Authorized Official - Last Name:WAGUESPACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-265-4087
Mailing Address - Street 1:1108 SAINT JAMES STREET
Mailing Address - Street 2:
Mailing Address - City:VACHERIE
Mailing Address - State:LA
Mailing Address - Zip Code:70090
Mailing Address - Country:US
Mailing Address - Phone:225-265-4087
Mailing Address - Fax:225-265-4006
Practice Address - Street 1:1108 SAINT JAMES ST
Practice Address - Street 2:
Practice Address - City:VACHERIE
Practice Address - State:LA
Practice Address - Zip Code:70090-5320
Practice Address - Country:US
Practice Address - Phone:225-265-4087
Practice Address - Fax:225-265-4006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA203080261QP2300X
LA23919174400000X
LA009974261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1442224Medicaid