Provider Demographics
NPI:1326815135
Name:SHOUSE, GERALD EDWARD II
Entity Type:Individual
Prefix:MR
First Name:GERALD
Middle Name:EDWARD
Last Name:SHOUSE
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3454 VILLA AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-7721
Mailing Address - Country:US
Mailing Address - Phone:318-208-6200
Mailing Address - Fax:
Practice Address - Street 1:3454 VILLA AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-7721
Practice Address - Country:US
Practice Address - Phone:318-208-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA211335163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool