Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207YX0007X | Plastic Surgeon (Head & Neck) | 022757 | LA |
NPI | 1427080043 |
---|---|
Provider Name | Kenneth Wayne Sanders |
First Address | Shreveport, LA 71105-5740 |
Second Address | Shreveport, LA 71106-6813 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/07/2006 |
Last Update Date | 30/09/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1686735 | (05) | LA |