Provider Demographics
NPI:1073879508
Name:DENICOLA, DUSTIN DAVID (NP)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:DAVID
Last Name:DENICOLA
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 84460
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70884-4460
Mailing Address - Country:US
Mailing Address - Phone:225-526-6001
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:4950 ESSEN LN
Practice Address - Street 2:SUITE 300
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3738
Practice Address - Country:US
Practice Address - Phone:225-490-8882
Practice Address - Fax:225-765-9085
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN117110-AP06574363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2314815Medicaid
MS00985562Medicaid
LA323052YJXSMedicare PIN