Provider Demographics
NPI:1164440418
Name:WASHBURN, DEBORAH JEAN (PA)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:JEAN
Last Name:WASHBURN
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 1:1512 W KIRBY PL
Mailing Address - Street 2:DEPARTMENT OF UROLOGY
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3822
Mailing Address - Country:US
Mailing Address - Phone:318-675-7636
Mailing Address - Fax:318-675-7531
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:DEPARTMENT OF UROLOGY
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-813-2750
Practice Address - Fax:318-813-2755
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10426363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5F600PE85OtherMEDICARE - PTAN
LA1624900Medicaid
LAS04586Medicare UPIN