Provider Demographics
NPI:1457593618
Name:MCMANUS, FALLON STROTHER (MD)
Entity type:Individual
Prefix:
First Name:FALLON
Middle Name:STROTHER
Last Name:MCMANUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 CENTRE SARCELLE BLVD
Mailing Address - Street 2:SUITE 506
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70592
Mailing Address - Country:US
Mailing Address - Phone:337-289-8978
Mailing Address - Fax:337-289-8977
Practice Address - Street 1:103 CENTRE SARCELLE BLVD
Practice Address - Street 2:SUITE 506
Practice Address - City:YOUNGSVILLE
Practice Address - State:LA
Practice Address - Zip Code:70592
Practice Address - Country:US
Practice Address - Phone:337-289-8978
Practice Address - Fax:337-289-8977
Is Sole Proprietor?:No
Enumeration Date:2009-04-01
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA204192207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1989673Medicaid