Provider Demographics
NPI:1861205379
Name:W PROFESSIONAL SURGICAL SERVICES PLLC
Entity type:Organization
Organization Name:W PROFESSIONAL SURGICAL SERVICES PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN & OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-748-5950
Mailing Address - Street 1:6608 N WESTERN AVE # 416
Mailing Address - Street 2:
Mailing Address - City:NICHOLS HILLS
Mailing Address - State:OK
Mailing Address - Zip Code:73116-7326
Mailing Address - Country:US
Mailing Address - Phone:405-748-5950
Mailing Address - Fax:405-607-3580
Practice Address - Street 1:10001 BROADWAY EXT STE A
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-6307
Practice Address - Country:US
Practice Address - Phone:405-748-5950
Practice Address - Fax:405-607-3580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-29
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & NeckGroup - Multi-Specialty