Healthcare Provider Details

I. General information

NPI: 1346296027
Provider Name (Legal Business Name): MATTHEW BLAINE THERIOT N.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2362 LARKSPUR LN
OPELOUSAS LA
70570-8674
US

IV. Provider business mailing address

2362 LARKSPUR LN
OPELOUSAS LA
70570-8674
US

V. Phone/Fax

Practice location:
  • Phone: 337-594-0675
  • Fax: 337-594-0850
Mailing address:
  • Phone: 337-594-0675
  • Fax: 337-594-0850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP04908
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAP04908
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: