1891784914 NPI number — SHAWNA NIKIA JEIDER PA

Table of content: ANDREW LEE BURNETT SA-C (NPI 1114270253)

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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