Basic Information
| Provider Information | |||||||||
| NPI: | 1689984536 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TYNDALL | ||||||||
| FirstName: | CIERRA | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HIDALGO | ||||||||
| OtherFirstName: | CIERRA | ||||||||
| OtherMiddleName: | M. | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 16435 | ||||||||
| Address2: | |||||||||
| City: | LOVES PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157132600 | ||||||||
| FaxNumber: | 8156548020 | ||||||||
| Practice Location | |||||||||
| Address1: | 1666 E. BERT KOUNS | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182123520 | ||||||||
| FaxNumber: | 3182123525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2010 | ||||||||
| LastUpdateDate: | 03/01/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA.200393 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | PA.200393 | LA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.