Provider Demographics
NPI:1912933110
Name:DOTY, SHIVA (PA-C)
Entity Type:Individual
Prefix:
First Name:SHIVA
Middle Name:
Last Name:DOTY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 KINGS HWY
Mailing Address - Street 2:EMERGENCY MEDICINE
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-675-7205
Mailing Address - Fax:318-675-6878
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:EMERGENCY MEDICINE
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-675-7205
Practice Address - Fax:318-675-6878
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA200026363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1151726Medicaid
LA1151726Medicaid