Healthcare Provider Details

I. General information

NPI: 1679518823
Provider Name (Legal Business Name): MARK J LANDRY NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 02/17/2023
Certification Date: 02/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3621 AMBASSADOR CAFFERY PKWY STE 100
LAFAYETTE LA
70503-5132
US

IV. Provider business mailing address

2851 JOHNSTON ST
LAFAYETTE LA
70503-3243
US

V. Phone/Fax

Practice location:
  • Phone: 337-534-4410
  • Fax:
Mailing address:
  • Phone: 337-456-3519
  • Fax: 337-534-4426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP04519
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberRN095042
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: