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General NPI Number Information
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NPI Number | 1538605027
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Entity Type | Individual
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Provider Name | MR. ANDREA BROUSSARD
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Gender | Male
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Dates
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Enumeration Date | 01/09/2017
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Last Update Date | 02/01/2019
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Provider Practice Location Address
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Address Line | 406 PASS RD
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City | GULFPORT
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State | MS
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Zip | 39507
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Country | US
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Telephone | 286-699-8402
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Fax |
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Provider Business Mailing Address
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Address Line | 406 PASS RD
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City | GULFPORT
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State | MS
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Zip | 39507-2901
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Country | US
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Telephone | 286-699-9840
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Fax |
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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 | 146D00000X
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Taxonomy Name | Personal Emergency Response Attendant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 172A00000X
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Taxonomy Name | Driver
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 3747P1801X
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Taxonomy Name | Personal Care Attendant
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 374U00000X
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Taxonomy Name | Home Health Aide
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License Number |
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License Number State | MS
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