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NPI Code Detail

MEDICARE: SHANNON KOVELESKIE

MEDICARE: SHANNON KOVELESKIE
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician AssistantPA.200784LA

General Provider Information

NPI Number : 1225417942
Entity Type Code : Individual
Provider Name (Legal Business Name) : SHANNON KOVELESKIE
Provider Business Mailing Address
First Line : 1860 FAIRFIELD AVE
Second Line :
City : SHREVEPORT
State : LA
Zip : 71101-4431
Country : US
Telephone Number : 318-675-1313
Fax Number : 318-675-1319
Provider Business Practice Location Address
First Line : 1860 FAIRFIELD AVE
Second Line :
City : SHREVEPORT
State : LA
Zip : 71101-4431
Country : US
Telephone Number : 318-675-1313
Fax Number : 318-675-1319
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/27/2015
Last Update Date : 05/27/2015

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Directions to “ SHANNON KOVELESKIE ” Practice Location

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