Provider Demographics
NPI:1104288679
Name:SHROCK, DAVID (PA-C)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:SHROCK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:601-200-4644
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:971 LAKELAND DR STE 356
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4607
Practice Address - Country:US
Practice Address - Phone:601-200-4644
Practice Address - Fax:601-200-4645
Is Sole Proprietor?:No
Enumeration Date:2016-03-24
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1234567890363AM0700X
MSPA00333363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical