Basic Information
Provider Information | |||||||||
NPI: | 1457372237 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | THOMAS | ||||||||
FirstName: | WANDA | ||||||||
MiddleName: | H | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WELLS | ||||||||
OtherFirstName: | WANDA | ||||||||
OtherMiddleName: | H | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1512 W KIRBY PL | ||||||||
Address2: |   | ||||||||
City: | SHREVEPORT | ||||||||
State: | LA | ||||||||
PostalCode: | 711033822 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3186758600 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1501 KINGS HWY | ||||||||
Address2: | DEPARTMENT OF PEDIATRICS | ||||||||
City: | SHREVEPORT | ||||||||
State: | LA | ||||||||
PostalCode: | 711034228 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3186758600 | ||||||||
FaxNumber: | 3186758638 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/21/2006 | ||||||||
LastUpdateDate: | 12/10/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 024938 | LA | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 4E967F600 | 01 | LA | MEDICARE - PTAN | OTHER | 1423092 | 05 | LA |   | MEDICAID |