Healthcare Provider Details

I. General information

NPI: 1326064742
Provider Name (Legal Business Name): PROFESSIONAL ANESTHESIA SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 03/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 SAINT LANDRY ST
LAFAYETTE LA
70506-4627
US

IV. Provider business mailing address

PO BOX 53864
LAFAYETTE LA
70505-3864
US

V. Phone/Fax

Practice location:
  • Phone: 337-289-2966
  • Fax: 337-289-2776
Mailing address:
  • Phone: 337-289-2966
  • Fax: 337-289-2776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT R THEARD
Title or Position: MANAGING MEMBER
Credential: MD
Phone: 337-289-2966