Basic Information
| Provider Information | |||||||||
| NPI: | 1285036582 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHEAD | ||||||||
| FirstName: | SHARLA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1718 S HENDERSON BLVD | ||||||||
| Address2: | |||||||||
| City: | KILGORE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756623544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9039832110 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2014 | ||||||||
| LastUpdateDate: | 06/12/2017 | ||||||||
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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 | 363LF0000X | AP126470 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 8075MD | 01 | TX | BCBS | OTHER | 75-2616977-017 | 01 | TX | TRICARE | OTHER | 340024402 | 05 | TX | MEDICAID |