Provider Demographics
NPI:1710227848
Name:SHOULTZ, RUSSELL TRICE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:TRICE
Last Name:SHOULTZ
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 DEMONTLUZIN AVE
Mailing Address - Street 2:
Mailing Address - City:BAY ST LOUIS
Mailing Address - State:MS
Mailing Address - Zip Code:39520
Mailing Address - Country:US
Mailing Address - Phone:228-363-3135
Mailing Address - Fax:
Practice Address - Street 1:1514 JEFFERSON HWY
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70121-2429
Practice Address - Country:US
Practice Address - Phone:504-842-4000
Practice Address - Fax:504-837-9271
Is Sole Proprietor?:No
Enumeration Date:2013-02-27
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR866996363LF0000X
LAAP08258363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05487222Medicaid
LA2395564Medicaid
LA2395564Medicaid