Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LN0000X | Nurse Practitioner - Neonatal | AP04669 | LA |
NPI | 1104022011 |
---|---|
Provider Name | Shane C Landreaux |
First Address | New Orleans, LA 70112-2821 |
Second Address | New Orleans, LA 70112-2821 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/06/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
AP04669 | STATE LICENSE NUMBER (01) | LA |