Healthcare Provider Details

I. General information

NPI: 1518604958
Provider Name (Legal Business Name): JOHN LUKE FRYOUX MSA, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2022
Last Update Date: 05/17/2022
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12035 LA-431
ST. AMANT LA
70774
US

IV. Provider business mailing address

10077 JUBAN CROSSING BLVD APT 604
DENHAM SPRINGS LA
70726-8039
US

V. Phone/Fax

Practice location:
  • Phone: 225-391-6000
  • Fax:
Mailing address:
  • Phone: 225-335-2370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number320899
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: