1417189465 NPI number — CLAY ERIC MORGAN PA-C

Table of content: CLAY ERIC MORGAN PA-C (NPI 1417189465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417189465 NPI number — CLAY ERIC MORGAN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MORGAN
Provider First Name:
CLAY
Provider Middle Name:
ERIC
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417189465
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/31/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1534 ELIZABETH AVE STE 301
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHREVEPORT
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71101-4531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-629-5001
Provider Business Mailing Address Fax Number:
318-629-5020

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 LINE AVENUE
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71101-4639
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-635-3052
Provider Business Practice Location Address Fax Number:
318-635-3072
Provider Enumeration Date:
08/10/2009

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 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 200336 , 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: P00845398 . This is a "RR" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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