Basic Information
| Provider Information | |||||||||
| NPI: | 1659393668 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | OLISTER | ||||||||
| FirstName: | STACI | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 HENRY CLAY AVE | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701185720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5044121860 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 HENRY CLAY AVE | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701185720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5044121860 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 04/03/2013 | ||||||||
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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 | 208000000X | 09320R | LA | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080N0001X | 09320R | LA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1965863 | 05 | LA | MEDICAID | 09173210 | 05 | MS | MEDICAID |