Provider Demographics
NPI:1659503613
Name:HAROLD, TREY M (PA)
Entity type:Individual
Prefix:
First Name:TREY
Middle Name:M
Last Name:HAROLD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1534 ELIZABETH AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4531
Mailing Address - Country:US
Mailing Address - Phone:318-629-5001
Mailing Address - Fax:318-629-5020
Practice Address - Street 1:1500 LINE AVENUE
Practice Address - Street 2:SUITE 100
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4639
Practice Address - Country:US
Practice Address - Phone:318-635-3052
Practice Address - Fax:318-635-3072
Is Sole Proprietor?:No
Enumeration Date:2009-08-10
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA363A00000X
LA200316363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAP00906263OtherRR
LA5B103PC07Medicare PIN
LAP00906263OtherRR
LA56770PB89Medicare PIN