Provider Demographics
NPI:1730118365
Name:GENTRY, TINA FAITH (PA)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:FAITH
Last Name:GENTRY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7925 YOUREE DR SUITE 280B
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5538
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7925 YOUREE DR SUITE 280B
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5538
Practice Address - Country:US
Practice Address - Phone:318-212-3636
Practice Address - Fax:318-212-3649
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10432363AM0700X
LAPAA10432363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1722901Medicaid
LAP40810Medicare UPIN
LA1722901Medicaid