Provider Demographics
NPI:1679537989
Name:HIDALGO, SHANNON TROY (DNP, FNP-BC)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:TROY
Last Name:HIDALGO
Suffix:
Gender:M
Credentials:DNP, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MSU BOX 90735
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70609-0001
Mailing Address - Country:US
Mailing Address - Phone:337-475-5748
Mailing Address - Fax:337-478-6196
Practice Address - Street 1:550 EAST SALE ROAD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70609-5052
Practice Address - Country:US
Practice Address - Phone:337-475-5748
Practice Address - Fax:337-478-6196
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP04423363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1466158Medicaid
LA1466158Medicaid
LAQ20860Medicare UPIN