Provider Demographics
NPI:1609853720
Name:SHOMO, RICHARD LEE (PA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:LEE
Last Name:SHOMO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 DEBORAH DR
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-5368
Mailing Address - Country:US
Mailing Address - Phone:504-678-8148
Mailing Address - Fax:504-678-1596
Practice Address - Street 1:2300 GENERAL MEYER AVE
Practice Address - Street 2:BLDG H100
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70142-0001
Practice Address - Country:US
Practice Address - Phone:504-678-8148
Practice Address - Fax:504-678-1596
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04261363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1037052Medicaid
1049767OtherNATIONAL CERTIFICATION
TXPA04261OtherLICENSE
LAPA200160OtherLICENSE
LA1037052Medicaid