Provider Demographics
NPI:1942438411
Name:MCTIRE, SHANNON L (NP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:MCTIRE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1500 LINE AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4639
Mailing Address - Country:US
Mailing Address - Phone:318-629-5505
Mailing Address - Fax:318-629-5506
Practice Address - Street 1:1500 LINE AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4639
Practice Address - Country:US
Practice Address - Phone:318-629-5001
Practice Address - Fax:318-629-5020
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2009-09-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LAAP05879363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA3B102B103Medicare PIN