Healthcare Provider Details

I. General information

NPI: 1205610607
Provider Name (Legal Business Name): LAKSAMANA PERINTIS NUSANTARA NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2023
Last Update Date: 10/23/2025
Certification Date: 10/23/2025
Deactivation Date: 04/18/2024
Reactivation Date: 05/30/2024

III. Provider practice location address

401 YOUNGSVILLE HWY STE 100
LAFAYETTE LA
70508-5173
US

IV. Provider business mailing address

401 YOUNGSVILLE HWY STE 100
LAFAYETTE LA
70508-5173
US

V. Phone/Fax

Practice location:
  • Phone: 337-451-0663
  • Fax: 337-205-8650
Mailing address:
  • Phone: 337-451-0663
  • Fax: 337-205-8650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11027192
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number234786
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: