Active NPI
Thea C Pennywell, PA
- Physician Assistant
- Shreveport, LA
National Provider Identifier
1295038149
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physician Assistant
- License
- PA200405
- Practice address
- 7925 Youree Dr
Suite 220
Shreveport, LA 71105-5127 - Phone
- (318) 424-3400
- Fax
- (318) 629-8712
- NPI assigned
- Dec 15, 2010
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | PA200405 | LA | Primary |
Addresses
Primary practice location
7925 Youree Dr
Suite 220
Shreveport, LA 71105-5127
Mailing address
7925 Youree Dr
Suite 220
Shreveport, LA 71105-5127
Phone (318) 424-3400
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PA200405 | LA | MD | Physician Assistant |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Laura Kimball-Ravari MD and Willis-Knighton Medical Center | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
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NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1292371200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1292371200000",
"number": "1295038149",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "7925 YOUREE DR",
"address_2": "SUITE 220",
"city": "SHREVEPORT",
"state": "LA",
"postal_code": "711055127",
"telephone_number": "318-424-3400",
"fax_number": "318-629-8712"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "7925 YOUREE DR",
"address_2": "SUITE 220",
"city": "SHREVEPORT",
"state": "LA",
"postal_code": "711055127",
"telephone_number": "318-424-3400",
"fax_number": "318-629-8712"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PENNYWELL",
"first_name": "THEA",
"middle_name": "C",
"credential": "PA",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2010-12-15",
"last_updated": "2010-12-15",
"status": "A"
},
"taxonomies": [
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "LA",
"license": "PA200405",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Shreveport, LA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 15, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.