Provider Demographics
NPI:1093845711
Name:EZERNACK, DIANE ALICIA (PT)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:ALICIA
Last Name:EZERNACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10101 PARK ROWE AVE
Mailing Address - Street 2:STE. 200
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-1686
Mailing Address - Country:US
Mailing Address - Phone:225-769-2200
Mailing Address - Fax:225-768-2185
Practice Address - Street 1:10101 PARK ROWE AVE
Practice Address - Street 2:STE. 200
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-1686
Practice Address - Country:US
Practice Address - Phone:225-769-2200
Practice Address - Fax:225-768-2185
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06806225100000X
OR06622225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4H529C492OtherMEDICARE
LA4H5297545Medicare PIN
LA4H529Medicare PIN