1619970308 NPI number — TRACY P BROUSSARD F.N.P.

Table of content: TRACY P BROUSSARD F.N.P. (NPI 1619970308)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619970308 NPI number — TRACY P BROUSSARD F.N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROUSSARD
Provider First Name:
TRACY
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
F.N.P.
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:
1619970308
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 52028
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:
70505-2028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-354-0030
Provider Business Mailing Address Fax Number:
337-354-0026

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
155 HOSPITAL DR
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70503-2852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-354-0030
Provider Business Practice Location Address Fax Number:
337-354-0026
Provider Enumeration Date:
05/27/2005

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:  RN087132 AP04548 , 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)





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