Provider Demographics
NPI:1104004720
Name:TYNES, KERRI LUCKEN (PA)
Entity Type:Individual
Prefix:
First Name:KERRI
Middle Name:LUCKEN
Last Name:TYNES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 HEARNE AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3931
Mailing Address - Country:US
Mailing Address - Phone:318-631-6400
Mailing Address - Fax:318-631-0300
Practice Address - Street 1:2300 HOSPITAL DR
Practice Address - Street 2:SUITE 450
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2394
Practice Address - Country:US
Practice Address - Phone:318-752-2328
Practice Address - Fax:318-746-0160
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10314363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAS63026Medicare UPIN