Healthcare Provider Details

I. General information

NPI: 1538605027
Provider Name (Legal Business Name): MR. ANDREA BROUSSARD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2017
Last Update Date: 02/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 PASS RD
GULFPORT MS
39507
US

IV. Provider business mailing address

406 PASS RD
GULFPORT MS
39507-2901
US

V. Phone/Fax

Practice location:
  • Phone: 286-699-8402
  • Fax:
Mailing address:
  • Phone: 286-699-9840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code146D00000X
TaxonomyPersonal Emergency Response Attendant
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: