Provider Demographics
NPI:1255618591
Name:CARPENTER, ANDRE' JACOB (PA)
Entity type:Individual
Prefix:MR
First Name:ANDRE'
Middle Name:JACOB
Last Name:CARPENTER
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:2751 ALBERT L BICKNELL DR
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3920
Mailing Address - Country:US
Mailing Address - Phone:318-212-4275
Mailing Address - Fax:318-212-4555
Practice Address - Street 1:2751 ALBERT L BICKNELL DR
Practice Address - Street 2:4TH FLOOR
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3920
Practice Address - Country:US
Practice Address - Phone:318-212-4275
Practice Address - Fax:318-212-4555
Is Sole Proprietor?:No
Enumeration Date:2011-11-15
Last Update Date:2021-06-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LAPA200495363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2173561Medicaid
LA57460PF84Medicare PIN