Healthcare Provider Details

I. General information

NPI: 1881369445
Provider Name (Legal Business Name): MR. PAUL ANANDA PATI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2021
Last Update Date: 11/08/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12589 AIRLINE HWY
DESTREHAN LA
70047-2501
US

IV. Provider business mailing address

1611 LAKE AVE
METAIRIE LA
70005-1413
US

V. Phone/Fax

Practice location:
  • Phone: 985-764-1158
  • Fax:
Mailing address:
  • Phone: 504-421-3718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number221847
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: