Provider Demographics
NPI:1952610883
Name:BETZING, SHANNON LEA (PA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEA
Last Name:BETZING
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 51008
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71135-1008
Mailing Address - Country:US
Mailing Address - Phone:318-798-9400
Mailing Address - Fax:318-798-3894
Practice Address - Street 1:2727 HEARNE AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3931
Practice Address - Country:US
Practice Address - Phone:318-798-9400
Practice Address - Fax:318-798-3894
Is Sole Proprietor?:No
Enumeration Date:2010-09-27
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200377363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2136364Medicaid
LA57720PD69Medicare PIN