Provider Demographics
NPI:1083605372
Name:GATLIN, KEVIN LEE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:LEE
Last Name:GATLIN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12393 OLD MILLSTONE DR
Mailing Address - Street 2:
Mailing Address - City:GEISMAR
Mailing Address - State:LA
Mailing Address - Zip Code:70734-3238
Mailing Address - Country:US
Mailing Address - Phone:225-673-1736
Mailing Address - Fax:
Practice Address - Street 1:12393 OLD MILLSTONE DR
Practice Address - Street 2:
Practice Address - City:GEISMAR
Practice Address - State:LA
Practice Address - Zip Code:70734-3238
Practice Address - Country:US
Practice Address - Phone:225-673-1736
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA96106367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1467341Medicaid
LA1467341Medicaid