Provider Demographics
NPI:1124492137
Name:COLEMAN, WESLEY
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 S FARMERVILLE ST
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-5941
Mailing Address - Country:US
Mailing Address - Phone:318-445-8380
Mailing Address - Fax:318-445-9753
Practice Address - Street 1:145 YORKTOWN DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-3621
Practice Address - Country:US
Practice Address - Phone:318-445-8380
Practice Address - Fax:318-445-9753
Is Sole Proprietor?:No
Enumeration Date:2015-11-16
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA300402363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant