Provider Demographics
NPI:1649376401
Name:HUMPHRIES, SHAWN MORETA (MD)
Entity type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:MORETA
Last Name:HUMPHRIES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:4104 CHATEAU BLVD
Mailing Address - Street 2:CONDO C
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065-5721
Mailing Address - Country:US
Mailing Address - Phone:504-464-7557
Mailing Address - Fax:985-325-8417
Practice Address - Street 1:200 W 134TH PL
Practice Address - Street 2:
Practice Address - City:CUT OFF
Practice Address - State:LA
Practice Address - Zip Code:70345-4143
Practice Address - Country:US
Practice Address - Phone:985-632-8256
Practice Address - Fax:985-325-8417
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA06675R207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1355739Medicaid
LAB64634Medicare UPIN
LA53462D358Medicare ID - Type Unspecified