Provider Demographics
NPI:1538200381
Name:WEASE, GARY LANE (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:LANE
Last Name:WEASE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1020 W FERTITTA BLVD
Mailing Address - Street 2:
Mailing Address - City:LEESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71446-4645
Mailing Address - Country:US
Mailing Address - Phone:337-419-0735
Mailing Address - Fax:337-238-5089
Practice Address - Street 1:201 S. ARKANSAS STREET
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446
Practice Address - Country:US
Practice Address - Phone:337-239-7227
Practice Address - Fax:337-238-4922
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA339940208600000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2649345Medicaid
LA3434512Medicaid
MI103347535Medicaid