Provider Demographics
NPI:1720267560
Name:PICKENS, SHANNON C (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:C
Last Name:PICKENS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 RUE SAINT LOUIS
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065-1773
Mailing Address - Country:US
Mailing Address - Phone:504-234-3288
Mailing Address - Fax:
Practice Address - Street 1:3926 BARRON ST STE C208
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-5797
Practice Address - Country:US
Practice Address - Phone:504-354-2064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD025591208D00000X
LA025591207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1050342Medicaid
LAMD025591OtherMEDICAL LICENSE