Provider Demographics
NPI:1457681850
Name:HART, DILLON HARRIS (ACNP-BC, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:DILLON
Middle Name:HARRIS
Last Name:HART
Suffix:
Gender:M
Credentials:ACNP-BC, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 IRVING PLACE
Mailing Address - Street 2:PROMISE HOSPITAL OF LOUISIANA
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101
Mailing Address - Country:US
Mailing Address - Phone:318-934-0550
Mailing Address - Fax:318-934-0451
Practice Address - Street 1:1800 IRVING PL
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4608
Practice Address - Country:US
Practice Address - Phone:318-934-0550
Practice Address - Fax:318-934-0451
Is Sole Proprietor?:No
Enumeration Date:2010-01-06
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN110727 AP05951363LA2100X
LAAP05951363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1814393Medicaid
LA3B649Medicare PIN