Provider Demographics
NPI:1891784914
Name:JEIDER, SHAWNA NIKIA (PA)
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:NIKIA
Last Name:JEIDER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SHAWNA
Other - Middle Name:NIKIA
Other - Last Name:VERDUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-765-5727
Mailing Address - Fax:225-765-4278
Practice Address - Street 1:7777 HENNESSY BLVD
Practice Address - Street 2:SUITE 211
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4300
Practice Address - Country:US
Practice Address - Phone:225-765-7163
Practice Address - Fax:225-765-7164
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200050363A00000X
LA200050363AM0700X
LA146363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1355615Medicaid
LA5CQ60P917Medicare PIN