Provider Demographics
NPI:1932409232
Name:DISOTELL, MEAGAN MARIE (NP)
Entity Type:Individual
Prefix:
First Name:MEAGAN
Middle Name:MARIE
Last Name:DISOTELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MEAGAN
Other - Middle Name:STEPHAN
Other - Last Name:DISOTELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:1501 KINGS HWY
Mailing Address - Street 2:DEPARTMENT OF PEDIATRICS (NICU)
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-675-6073
Mailing Address - Fax:
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:DEPARTMENT OF PEDIATRICS (NICU)
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-675-6073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAPO6273363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care