1902894595 NPI number — LARA CORNELIA THIBODEAUX NP

Table of content: LARA CORNELIA THIBODEAUX NP (NPI 1902894595)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902894595 NPI number — LARA CORNELIA THIBODEAUX NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THIBODEAUX
Provider First Name:
LARA
Provider Middle Name:
CORNELIA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOYETT
Provider Other First Name:
LARA
Provider Other Middle Name:
CORNELIA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1902894595
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1500 UNIVERSITY DR E
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
COLLEGE STATION
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77840-2600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
979-846-1100
Provider Business Mailing Address Fax Number:
979-260-9390

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
808 W US HIGHWAY 79
Provider Second Line Business Practice Location Address:
2880
Provider Business Practice Location Address City Name:
FRANKLIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77856
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-282-4540
Provider Business Practice Location Address Fax Number:
979-828-3006
Provider Enumeration Date:
10/08/2005

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:  593517 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1841562451 . This is a "FACILITY NPI (SJHP FRANKLIN)" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 2952517-01 . This is a "BVCAA DBA ST,. JOSEPH HEALTH POINT FRANKLIN MEDICAID (PTAN) NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 67-1981 . This is a "BVCAA DBA: ST. JOSEPH HEALTH POINT FRANKLIN PTAN (MEDICARE NUMBER)" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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