Healthcare Provider Details

I. General information

NPI: 1043858152
Provider Name (Legal Business Name): JUSTIN K FUQUA CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2019
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 HENNESSY BLVD
BATON ROUGE LA
70808-4375
US

IV. Provider business mailing address

7777 HENNESSY BLVD STE 301
BATON ROUGE LA
70808-0319
US

V. Phone/Fax

Practice location:
  • Phone: 225-765-8541
  • Fax:
Mailing address:
  • Phone: 225-214-6438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2024010874
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN783971
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number210093
License Number StateLA
# 4
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1031265
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: