Healthcare Provider Details

I. General information

NPI: 1184678997
Provider Name (Legal Business Name): MARK A. ST. CYR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 04/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 JEFFERSON ST
LAFAYETTE LA
70501-8556
US

IV. Provider business mailing address

2100 JEFFERSON ST
LAFAYETTE LA
70501-8556
US

V. Phone/Fax

Practice location:
  • Phone: 337-261-0734
  • Fax:
Mailing address:
  • Phone: 337-261-0734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number018991
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: