Healthcare Provider Details

I. General information

NPI: 1982915195
Provider Name (Legal Business Name): TARISHA RENEE MIXON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2010
Last Update Date: 09/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 NORTH BLVD STE 200-A
BATON ROUGE LA
70806-3743
US

IV. Provider business mailing address

8490 PICARDY AVE BLDG 200
BATON ROUGE LA
70809-3731
US

V. Phone/Fax

Practice location:
  • Phone: 225-387-0851
  • Fax: 225-383-8477
Mailing address:
  • Phone: 225-237-1754
  • Fax: 225-237-1722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD.205942
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: