1720267560 NPI number — DR. SHANNON C PICKENS MD

Table of content: DR. SHANNON C PICKENS MD (NPI 1720267560)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720267560 NPI number — DR. SHANNON C PICKENS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PICKENS
Provider First Name:
SHANNON
Provider Middle Name:
C
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1720267560
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18 RUE SAINT LOUIS
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENNER
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70065-1773
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-234-3288
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3926 BARRON ST STE C208
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
METAIRIE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70002-5797
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-354-2064
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/29/2007

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: 208D00000X , with the licence number:  MD025591 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207N00000X , with the licence number: 025591 , 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: 1050342 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: MD025591 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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