Provider Demographics
NPI:1578720793
Name:UPTON, LATASHIA
Entity Type:Individual
Prefix:
First Name:LATASHIA
Middle Name:
Last Name:UPTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 HOMER RD
Mailing Address - Street 2:
Mailing Address - City:MINDEN
Mailing Address - State:LA
Mailing Address - Zip Code:71055-2933
Mailing Address - Country:US
Mailing Address - Phone:318-377-8855
Mailing Address - Fax:318-377-8852
Practice Address - Street 1:431 HOMER RD
Practice Address - Street 2:
Practice Address - City:MINDEN
Practice Address - State:LA
Practice Address - Zip Code:71055-2933
Practice Address - Country:US
Practice Address - Phone:318-377-8855
Practice Address - Fax:318-377-8852
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LAMD.204147207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA06384Medicaid