Provider Demographics
NPI:1740646355
Name:ANTHONY-MCALLISTER, MISTY MARLENE (PA-C, MPAS)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:MARLENE
Last Name:ANTHONY-MCALLISTER
Suffix:
Gender:F
Credentials:PA-C, MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 E STONER AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4243
Mailing Address - Country:US
Mailing Address - Phone:318-221-8411
Mailing Address - Fax:
Practice Address - Street 1:510 E STONER AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4243
Practice Address - Country:US
Practice Address - Phone:318-221-8411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-12
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA300091363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
13653665OtherCAQH
2645976OtherWELLCARE
7771259OtherMULTIPLAN (PHCS)
QZZ000000106926OtherAETNA BETTER HEALTH
6261862OtherAETNA
0246933OtherCIGNA
1740646355OtherHEALTHY BLUE
2869917OtherFIRST HEALTH
LA60326536OtherAMERIHEALTH CARITAS
LA1740646355OtherLA HEALTHCARE CONNECTIONS
LA2424076Medicaid
146475OtherVANTAGE HEALTH PLAN