1396951307 NPI number — RANDALL K WAGMAN MD APMC

Table of content: (NPI 1396951307)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396951307 NPI number — RANDALL K WAGMAN MD APMC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RANDALL K WAGMAN MD APMC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396951307
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2345 SAMPSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTLAKE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70669-2711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-439-1484
Provider Business Mailing Address Fax Number:
337-430-0927

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2345 SAMPSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTLAKE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70669-2711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-439-1484
Provider Business Practice Location Address Fax Number:
337-430-0927
Provider Enumeration Date:
05/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WAGMAN
Authorized Official First Name:
RANDALL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
337-439-1484

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  11202R , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1945323 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com