Basic Information
| Provider Information | |||||||||
| NPI: | 1134469463 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCURLOCK | ||||||||
| FirstName: | HOLLY | ||||||||
| MiddleName: | GAINES | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9300 MANSFIELD RD | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711183155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186293763 | ||||||||
| FaxNumber: | 3186293767 | ||||||||
| Practice Location | |||||||||
| Address1: | 9300 MANSFIELD RD | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711183155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186293763 | ||||||||
| FaxNumber: | 3186293767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2013 | ||||||||
| LastUpdateDate: | 02/23/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA.200600 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.