Provider Demographics
NPI:1699792671
Name:STOUGH, CHERYL CLINE (PA)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:CLINE
Last Name:STOUGH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 KINGS HWY
Mailing Address - Street 2:DEPARTMENT OF EMERGENCY MEDICINE
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-675-7205
Mailing Address - Fax:318-675-6878
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:DEPARTMENT OF EMERGENCY MEDICINE
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-675-7205
Practice Address - Fax:318-675-6878
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10271363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1626023Medicaid
LA1626023Medicaid
LA5F600PB39Medicare PIN