Lori A Stackow, PAC

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

332160 Issued in LA

Practice address

1541 Kings Hwy
Shreveport, LA 71103-4228

Phone

(318) 626-0000

Fax

(318) 629-4833

NPI assigned

Sep 30, 2005

Last updated

Feb 22, 2023By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 7

Other names 1

• Lori A Rudderow Former name

Medicare fee-for-service enrollment

Enrolled in LA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Physician Assistant

Education

Other, 1991

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Lsu Health Sciences Center Shreveport Faculty Group PracticeGroup PAC ID 4082902721, 567 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Ochsner Lsu Health Shreveport Hospital, Shreveport, LA, CCN 190098
• Ochsner Lsu Health Shreveport-St Mary Medical Cent Hospital, Shreveport, LA, CCN 190317

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Lsu Health Sciences Center Shreveport Faculty Group Practice

  • Family Medicine Physician
  • Shreveport, LA
  • NPI 1013374222
  Medicare reassignment Care Compare group
• Cross Lake Emergency Group, LLC

  • Emergency Medicine Physician
  • Shreveport, LA
  • NPI 1013497114
  Medicare reassignment
• Brfhh Shreveport LLC

  dba University Health Shreveport

  • General Acute Care Hospital
  • Shreveport, LA
  • NPI 1912909912
  NPD (past)
• University Health Shreveport LLC

  dba Ochsner LSU Health Shreveport

  • Nurse Practitioner
  • Shreveport, LA
  • NPI 1619443611

  Physician Assistant

  NPD (past)

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• Ochsner Lsu Health Shreveport - St. Mary Medical Center, LLC

  dba Ochsner LSU Health Shreveport - St. Mary Medical Center

  • Women's Hospital
  • Shreveport, LA
  • NPI 1285253252
  Care Compare affiliation
• University Health Shreveport LLC

  dba Ochsner LSU Health Shreveport

  • General Acute Care Hospital
  • Shreveport, LA
  • NPI 1427536325
  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1128038400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1677024000000",
    "number": "1467449835",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1512 W KIRBY PL",
            "city": "SHREVEPORT",
            "state": "LA",
            "postal_code": "711033822",
            "telephone_number": "318-626-0177"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1541 KINGS HWY",
            "city": "SHREVEPORT",
            "state": "LA",
            "postal_code": "711034228",
            "telephone_number": "318-626-0000",
            "fax_number": "318-629-4833"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "6400 Fannin St Ste 2800",
            "address_purpose": "LOCATION",
            "city": "Houston",
            "state": "TX",
            "postal_code": "770301534",
            "country_code": "US",
            "telephone_number": "713-704-7100",
            "fax_number": "713-704-1262",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "STACKOW",
        "first_name": "LORI",
        "middle_name": "A",
        "name_prefix": "Mrs.",
        "credential": "PAC",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2005-09-30",
        "last_updated": "2023-02-22",
        "certification_date": "2023-02-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "TX",
            "license": "PA10687",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "LA",
            "license": "332160",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "153449704",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DEEIOC",
            "identifier": "601417200",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "004385800",
            "state": "ID"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8434896",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "REGENCE BS OF ID",
            "identifier": "000010017182",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DEPT OF LABOR AND INDUSTR",
            "identifier": "49008",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS OF ID",
            "identifier": "PAJB6",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "LORI",
            "last_name": "RUDDEROW",
            "middle_name": "A",
            "credential": "PAC",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

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• Physician Assistant in Shreveport, LA
• Providers in Shreveport, LA by specialty
• Physician Assistant in Louisiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 22, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.