Healthcare Provider Details

I. General information

NPI: 1407151913
Provider Name (Legal Business Name): DUSTIN COLE BROUSSARD CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2011
Last Update Date: 10/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 GRAMMONT ST STE 100
MONROE LA
71201-7457
US

IV. Provider business mailing address

PO BOX 3185
MONROE LA
71210-3185
US

V. Phone/Fax

Practice location:
  • Phone: 318-998-6129
  • Fax:
Mailing address:
  • Phone: 318-998-6129
  • Fax: 318-812-1755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN9306451
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP06688
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: