1891784914 NPI number — SHAWNA NIKIA JEIDER PA

Table of content: SHAWNA NIKIA JEIDER PA (NPI 1891784914)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891784914 NPI number — SHAWNA NIKIA JEIDER PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JEIDER
Provider First Name:
SHAWNA
Provider Middle Name:
NIKIA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VERDUN
Provider Other First Name:
SHAWNA
Provider Other Middle Name:
NIKIA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1891784914
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5959 S SHERWOOD FOREST BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70816-6038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-765-5727
Provider Business Mailing Address Fax Number:
225-765-4278

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7777 HENNESSY BLVD
Provider Second Line Business Practice Location Address:
SUITE 211
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70808-4300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-765-7163
Provider Business Practice Location Address Fax Number:
225-765-7164
Provider Enumeration Date:
10/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA.200050 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: 200050 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: 146 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1355615 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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