Healthcare Provider Details

I. General information

NPI: 1093325409
Provider Name (Legal Business Name): MR. JUSTIN ROBERT RAGON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2020
Last Update Date: 03/10/2021
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 CIVIC CENTER BLVD
HOUMA LA
70360-5937
US

IV. Provider business mailing address

1505 N FLORIDA ST
COVINGTON LA
70433-1544
US

V. Phone/Fax

Practice location:
  • Phone: 985-333-2020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number904119
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberC-APN.0002218-C-NP
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number200327
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: