Provider Demographics
NPI:1003129891
Name:LAMAR UNIVERSITY STUDENT HEALTH CTR
Entity Type:Organization
Organization Name:LAMAR UNIVERSITY STUDENT HEALTH CTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COORDINATOR/NURSE
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:RNMSNENP
Authorized Official - Phone:409-880-8466
Mailing Address - Street 1:P O BOX 10015
Mailing Address - Street 2:857 E VIRGINIA
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77710-5546
Mailing Address - Country:US
Mailing Address - Phone:409-880-8466
Mailing Address - Fax:409-880-7703
Practice Address - Street 1:857 E VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77705-5546
Practice Address - Country:US
Practice Address - Phone:409-880-8466
Practice Address - Fax:409-880-7703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-21
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX618115363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP50618Medicare UPIN