Basic Information
| Provider Information | |||||||||
| NPI: | 1639346216 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORT | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1501 KINGS HWY | ||||||||
| Address2: | DEPARTMENT OF FAMILY MEDICINE | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711034228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186755000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1501 KINGS HWY | ||||||||
| Address2: | DEPARTMENT OF FAMILY MEDICINE | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711034228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186755000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2008 | ||||||||
| LastUpdateDate: | 01/22/2015 | ||||||||
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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 | 363A00000X | PA 200178 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1065676 | 05 | LA | MEDICAID |