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General NPI Number Information
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NPI Number | 1205610607
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Entity Type | Individual
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Provider Name | LAKSAMANA PERINTIS NUSANTARA NP
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Gender | Male
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Dates
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Enumeration Date | 08/24/2023
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Last Update Date | 10/23/2025
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Provider Practice Location Address
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Address Line | 401 YOUNGSVILLE HWY STE 100
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City | LAFAYETTE
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State | LA
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Zip | 70508-5173
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Country | US
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Telephone | 337-451-0663
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Fax | 337-205-8650
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Provider Business Mailing Address
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Address Line | 401 YOUNGSVILLE HWY STE 100
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City | LAFAYETTE
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State | LA
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Zip | 70508-5173
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Country | US
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Telephone | 337-451-0663
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Fax | 337-205-8650
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 11027192
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number | 234786
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License Number State | LA
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