1063796407 NPI number — MRS. MAREESA PERRAULT MATHERS FNP

Table of content: MRS. MAREESA PERRAULT MATHERS FNP (NPI 1063796407)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063796407 NPI number — MRS. MAREESA PERRAULT MATHERS FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATHERS
Provider First Name:
MAREESA
Provider Middle Name:
PERRAULT
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PERRAULT
Provider Other First Name:
MAREESA
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063796407
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2390 W CONGRESS ST
Provider Second Line Business Mailing Address:
ONCOLOGY DEPARTMENT, 5NORTH
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70506-4205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-261-6515
Provider Business Mailing Address Fax Number:
337-261-6555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2730 AMBASSADOR CAFFERY PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70506-5939
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-988-1585
Provider Business Practice Location Address Fax Number:
337-981-4694
Provider Enumeration Date:
10/04/2011

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: 363L00000X , with the licence number:  06624 , 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: 2190261 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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