Healthcare Provider Details

I. General information

NPI: 1205290640
Provider Name (Legal Business Name): JOSHUA FAY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2016
Last Update Date: 09/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 JUDGE TANNER BLVD
COVINGTON LA
70433-7500
US

IV. Provider business mailing address

4 WILLOW CREEK LN APT 4205
JONESBORO AR
72404-7990
US

V. Phone/Fax

Practice location:
  • Phone: 540-761-7371
  • Fax:
Mailing address:
  • Phone: 985-981-2299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP09660
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: