Provider Demographics
NPI:1053646125
Name:JUNEAU, KYLE DAMON (NP)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:DAMON
Last Name:JUNEAU
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7777 HENNESSY BLVD
Mailing Address - Street 2:SUITE 1004-154
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4300
Mailing Address - Country:US
Mailing Address - Phone:225-214-9352
Mailing Address - Fax:225-214-9349
Practice Address - Street 1:12525 PERKINS RD
Practice Address - Street 2:SUITE B
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-1907
Practice Address - Country:US
Practice Address - Phone:225-819-8857
Practice Address - Fax:225-767-6822
Is Sole Proprietor?:No
Enumeration Date:2009-10-07
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LAPERMIT 2187363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1805548Medicaid
LA1805548Medicaid
LA295966YJA2Medicare PIN
LA3B521DE56Medicare PIN