Doctor Name: | RONALD NEIL MABERRY |
NPI Number: | 1043321631 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | PA-C |
License Number: | |
Business Practice Address: | 510 E Stoner Ave (111c) Shreveport, LA - 711014243 |
Business Phone Number: | 3184246064 |
Business Fax Number: | |
Mailing Address: | 137 Promenade Ave, SHREVEPORT |
State: | LA |
Postal Code: | 711153241 |
Phone Number: | 3187980030 |
Fax Number: | |
NPI Enumeration Date: | 08/31/2006 |
NPI Last Update Date: | 07/08/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 363AM0700X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | |
Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
Taxonomy Classification: | Physician Assistant |
Taxonomy Specialization: | Medical |
Taxonomy Definition: |