Basic Information
| Provider Information | |||||||||
| NPI: | 1841371150 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRIZZARD | ||||||||
| FirstName: | SHAYNE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 98509 | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708849509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257692200 | ||||||||
| FaxNumber: | 2257682185 | ||||||||
| Practice Location | |||||||||
| Address1: | 10101 PARK ROWE AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708101685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257692200 | ||||||||
| FaxNumber: | 2257682185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 03/28/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | A10365 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1626473 | 05 | LA | MEDICAID |