Basic Information
| Provider Information | |||||||||
| NPI: | 1255618591 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARPENTER | ||||||||
| FirstName: | ANDRE' | ||||||||
| MiddleName: | JACOB | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2751 ALBERT L BICKNELL DR | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711033920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182124275 | ||||||||
| FaxNumber: | 3182124555 | ||||||||
| Practice Location | |||||||||
| Address1: | 2751 ALBERT L BICKNELL DR | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711033920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182124275 | ||||||||
| FaxNumber: | 3182124555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2011 | ||||||||
| LastUpdateDate: | 06/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA200495 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2173561 | 05 | LA | MEDICAID |