Healthcare Provider Details

I. General information

NPI: 1033390398
Provider Name (Legal Business Name): CARSON ELIZABETH SHETLEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2007
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1666 E BERT KOUNS INDUSTRIAL LOOP STE 105
SHREVEPORT LA
71105-5718
US

IV. Provider business mailing address

1666 E BERT KOUNS INDUSTRIAL LOOP STE 105
SHREVEPORT LA
71105-5718
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-3520
  • Fax: 318-212-3525
Mailing address:
  • Phone: 318-212-3520
  • Fax: 318-212-3525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA200181
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA07206
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: