Healthcare Provider Details

I. General information

NPI: 1619241064
Provider Name (Legal Business Name): GREG A BROUSSARD CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2012
Last Update Date: 03/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 AMBASSADOR CAFFERY PKWY
LAFAYETTE LA
70508-6917
US

IV. Provider business mailing address

PO BOX 53864
LAFAYETTE LA
70505-3864
US

V. Phone/Fax

Practice location:
  • Phone: 337-470-2966
  • Fax: 337-470-2776
Mailing address:
  • Phone: 337-470-2966
  • Fax: 337-470-2776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN112825AP06765
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: