Basic Information
Provider Information | |||||||||
NPI: | 1174027411 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FONDREN | ||||||||
FirstName: | WREN | ||||||||
MiddleName: | HARRISON | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FONDREN | ||||||||
OtherFirstName: | CATHERINE | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1631 ELYSIAN FIELDS AVE | ||||||||
Address2: |   | ||||||||
City: | NEW ORLEANS | ||||||||
State: | LA | ||||||||
PostalCode: | 701178208 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5048212601 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1631 ELYSIAN FIELDS AVE | ||||||||
Address2: |   | ||||||||
City: | NEW ORLEANS | ||||||||
State: | LA | ||||||||
PostalCode: | 701178208 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5048212601 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/21/2018 | ||||||||
LastUpdateDate: | 07/22/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/14/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 326449 | LA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.