Basic Information
| Provider Information | |||||||||
| NPI: | 1306844147 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HALL | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2647 S SAINT ELIZABETH BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707375019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257655500 | ||||||||
| FaxNumber: | 2256445415 | ||||||||
| Practice Location | |||||||||
| Address1: | 2647 S SAINT ELIZABETH BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707375019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257655500 | ||||||||
| FaxNumber: | 2256445415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 03/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 10010R | LA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1970816 | 05 | LA | MEDICAID |