=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083467104
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DUSTIN ROSS CARLISLE NP-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2024
-----------------------------------------------------
Last Update Date | 11/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1811 E BERT KOUNS INDUSTRIAL LOOP STE 210
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71105-5740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-212-3858
-----------------------------------------------------
Fax | 318-212-3958
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1811 E BERT KOUNS INDUSTRIAL LOOP STE 210
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71105-5740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-212-3858
-----------------------------------------------------
Fax | 318-212-3958
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 232197
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------