Healthcare Provider Details

I. General information

NPI: 1518931229
Provider Name (Legal Business Name): EDMON LISTON MAPP JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 BOONER MILLER RD
DEVILLE LA
71328-9445
US

IV. Provider business mailing address

163 BOONER MILLER RD
DEVILLE LA
71328-9445
US

V. Phone/Fax

Practice location:
  • Phone: 318-443-1700
  • Fax: 318-443-1703
Mailing address:
  • Phone: 318-443-1700
  • Fax: 318-443-1703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number40557
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number704026
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: