Healthcare Provider Details

I. General information

NPI: 1093034373
Provider Name (Legal Business Name): JEROME CHARLES MAUTERER SR. CSTFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2010
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490 MARINA DR
SLIDELL LA
70458-9204
US

IV. Provider business mailing address

490 MARINA DR
SLIDELL LA
70458-9204
US

V. Phone/Fax

Practice location:
  • Phone: 985-445-6902
  • Fax:
Mailing address:
  • Phone: 985-445-6902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: