Healthcare Provider Details

I. General information

NPI: 1639372105
Provider Name (Legal Business Name): NICHOLAS CHARLES PATIN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 05/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1214 COOLIDGE BLVD
LAFAYETTE LA
70503-2621
US

IV. Provider business mailing address

PO BOX 1123 255 W MICHIGAN AVE
JACKSON MI
49201-2218
US

V. Phone/Fax

Practice location:
  • Phone: 337-289-7991
  • Fax:
Mailing address:
  • Phone: 800-242-1131
  • Fax: 517-787-4146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN107416
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: