Basic Information
| Provider Information | |||||||||
| NPI: | 1891784914 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JEIDER | ||||||||
| FirstName: | SHAWNA | ||||||||
| MiddleName: | NIKIA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VERDUN | ||||||||
| OtherFirstName: | SHAWNA | ||||||||
| OtherMiddleName: | NIKIA | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5959 S SHERWOOD FOREST BLVD | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708166038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257655727 | ||||||||
| FaxNumber: | 2257654278 | ||||||||
| Practice Location | |||||||||
| Address1: | 7777 HENNESSY BLVD | ||||||||
| Address2: | SUITE 211 | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708084300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257657163 | ||||||||
| FaxNumber: | 2257657164 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2005 | ||||||||
| LastUpdateDate: | 06/22/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA.200050 | LA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 200050 | LA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | 146 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1355615 | 05 | LA | MEDICAID |