Healthcare Provider Details

I. General information

NPI: 1801425087
Provider Name (Legal Business Name): KAITLYN P BRISCOE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2020
Last Update Date: 04/08/2020
Certification Date: 04/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S 6TH ST STE A
LEESVILLE LA
71446-4470
US

IV. Provider business mailing address

500 S 6TH ST STE A
LEESVILLE LA
71446-4470
US

V. Phone/Fax

Practice location:
  • Phone: 337-239-8000
  • Fax: 337-239-8003
Mailing address:
  • Phone: 337-239-8000
  • Fax: 337-239-8003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number322198
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number322198
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: