=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881369445
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. PAUL ANANDA PATI
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2021
-----------------------------------------------------
Last Update Date | 11/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12589 AIRLINE HWY
-----------------------------------------------------
City | DESTREHAN
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70047-2501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-764-1158
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1611 LAKE AVE
-----------------------------------------------------
City | METAIRIE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70005-1413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-421-3718
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 221847
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------