Provider Demographics
NPI:1952857807
Name:SHANKS, MARJORIE (PA)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:
Last Name:SHANKS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3704 NORTH BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-3658
Mailing Address - Country:US
Mailing Address - Phone:318-443-4576
Mailing Address - Fax:
Practice Address - Street 1:3704 NORTH BLVD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3658
Practice Address - Country:US
Practice Address - Phone:318-443-4576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA303153363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant