Healthcare Provider Details

I. General information

NPI: 1477925196
Provider Name (Legal Business Name): SYDNEY F FUSSELL PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2015
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 S TYLER ST STE 100
COVINGTON LA
70433-2353
US

IV. Provider business mailing address

4950 ESSEN LN
BATON ROUGE LA
70809-3738
US

V. Phone/Fax

Practice location:
  • Phone: 985-892-9090
  • Fax: 985-892-9957
Mailing address:
  • Phone: 225-767-0847
  • Fax: 225-766-0218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA.200805
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: