Healthcare Provider Details

I. General information

NPI: 1861588667
Provider Name (Legal Business Name): CARLOS A BROUSSARD CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 03/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N LEWIS ST
NEW IBERIA LA
70560
US

IV. Provider business mailing address

PO BOX 52533
LAFAYETTE LA
70505
US

V. Phone/Fax

Practice location:
  • Phone: 337-365-3168
  • Fax: 337-369-3536
Mailing address:
  • Phone: 337-365-3168
  • Fax: 337-369-3536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number04660
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: