Healthcare Provider Details

I. General information

NPI: 1790287746
Provider Name (Legal Business Name): MATTHEW TYLER KHOSROPOUR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2018
Last Update Date: 03/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 E SAINT PETER ST
NEW IBERIA LA
70560-3932
US

IV. Provider business mailing address

1012 PETROLEUM PKWY
BROUSSARD LA
70518-8020
US

V. Phone/Fax

Practice location:
  • Phone: 337-364-1166
  • Fax: 337-364-7090
Mailing address:
  • Phone: 337-465-2159
  • Fax: 337-465-4604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP09821
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: