1396764189 NPI number — DRU M. PATIN CRNA

Table of content: DRU M. PATIN CRNA (NPI 1396764189)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396764189 NPI number — DRU M. PATIN CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PATIN
Provider First Name:
DRU
Provider Middle Name:
M.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396764189
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 60605
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70596-0605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-981-0305
Provider Business Mailing Address Fax Number:
337-981-9257

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4630 AMBASSADOR CAFFERY PKWY
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70508-6949
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-981-6005
Provider Business Practice Location Address Fax Number:
337-988-3059
Provider Enumeration Date:
07/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  AP01418 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1931284 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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