Provider Demographics
NPI:1962121855
Name:GIDDY UP PEDIATRICS
Entity type:Organization
Organization Name:GIDDY UP PEDIATRICS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:C
Authorized Official - Last Name:CHANLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-372-8797
Mailing Address - Street 1:1503 GOODWIN RD STE 1
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-2938
Mailing Address - Country:US
Mailing Address - Phone:318-781-2310
Mailing Address - Fax:
Practice Address - Street 1:600 FACTORY OUTLET DR STE 12
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:LA
Practice Address - Zip Code:71001-3057
Practice Address - Country:US
Practice Address - Phone:318-372-8797
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-24
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2387421Medicaid