Provider Demographics
NPI:1700222379
Name:MCVAY, SHANE M (FNP)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:M
Last Name:MCVAY
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 S FARMERVILLE ST
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-5941
Mailing Address - Country:US
Mailing Address - Phone:318-255-3690
Mailing Address - Fax:
Practice Address - Street 1:4707 QUITMAN HIGHWAY
Practice Address - Street 2:
Practice Address - City:HODGE
Practice Address - State:LA
Practice Address - Zip Code:71247
Practice Address - Country:US
Practice Address - Phone:318-395-1168
Practice Address - Fax:318-395-1170
Is Sole Proprietor?:No
Enumeration Date:2013-05-22
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LATAP003048363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily