Basic Information
| Provider Information | |||||||||
| NPI: | 1306434832 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VAN ASSOCIATES NEPHROLOGY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10297 ELLERBE RD | ||||||||
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| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711067708 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1800 IRVING PL | ||||||||
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| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711014608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184254096 | ||||||||
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| ProviderEnumerationDate: | 01/10/2021 | ||||||||
| LastUpdateDate: | 01/10/2021 | ||||||||
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| AuthorizedOfficialLastName: | VAN | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9546556852 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 01/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.