Basic Information
Provider Information | |||||||||
NPI: | 1932310687 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARPER | ||||||||
FirstName: | SHEYENNE | ||||||||
MiddleName: | W | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WILBORN | ||||||||
OtherFirstName: | SHEYENNE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 845 OLIVE ST | ||||||||
Address2: | SUITE A | ||||||||
City: | SHREVEPORT | ||||||||
State: | LA | ||||||||
PostalCode: | 711042141 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3182264892 | ||||||||
FaxNumber: | 3182274927 | ||||||||
Practice Location | |||||||||
Address1: | 845 OLIVE ST | ||||||||
Address2: | SUITE A | ||||||||
City: | SHREVEPORT | ||||||||
State: | LA | ||||||||
PostalCode: | 711042141 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3182264892 | ||||||||
FaxNumber: | 3182274927 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/24/2007 | ||||||||
LastUpdateDate: | 06/21/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/21/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 200925 | LA | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | MD.200925 | LA | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 21472 | 05 | LA |   | MEDICAID | 180367001 | 05 | AR |   | MEDICAID | 209258701 | 05 | TX |   | MEDICAID | 1214728 | 05 | LA |   | MEDICAID |