Healthcare Provider Details

I. General information

NPI: 1053384495
Provider Name (Legal Business Name): DAVID MICHAEL LOFSTROM A.P.R.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 08/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 SOUTH VIENNA
RUSTON LA
71270-5845
US

IV. Provider business mailing address

1809 NORTHPOINTE LANE SUITE 203
RUSTON LA
71270-3852
US

V. Phone/Fax

Practice location:
  • Phone: 318-251-8001
  • Fax: 318-699-8845
Mailing address:
  • Phone: 318-251-8001
  • Fax: 318-699-8843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberRN073531
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberRN073531
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN073531-AP03121
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: