Provider Demographics
NPI:1619977592
Name:PRYOR, EVELYN BARANCO (MD)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:BARANCO
Last Name:PRYOR
Suffix:
Gender:F
Credentials:MD
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:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3822
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1541 KINGS HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-626-0000
Practice Address - Fax:318-629-4833
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053976207R00000X
LA326734207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA149934368BMedicaid
NC1619977592Medicaid
SCQ0158HMedicaid
NC5905358Medicaid
NCP00378172OtherRAILROAD MEDICARE
NC2061896Medicare PIN
NCNCA980AMedicare PIN
NC2061896AMedicare PIN
GA149934368BMedicaid
SCQ0158HMedicaid
NC5905358Medicaid