1457383739 NPI number — ANDERSON CLARK AUSTIN FNPC

Table of content: ANDERSON CLARK AUSTIN FNPC (NPI 1457383739)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457383739 NPI number — ANDERSON CLARK AUSTIN FNPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AUSTIN
Provider First Name:
ANDERSON
Provider Middle Name:
CLARK
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNPC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
AUSTIN
Provider Other First Name:
ANDY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNPC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1457383739
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5959 S SHERWOOD FOREST BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70816-6038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-966-4400
Provider Business Mailing Address Fax Number:
225-765-9196

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
309 JACKSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71201-7407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-966-4000
Provider Business Practice Location Address Fax Number:
318-966-7359
Provider Enumeration Date:
07/07/2006

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: 363LF0000X , with the licence number:  AP04485 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: RN094896 AP04485 , 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: 1073580 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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