Provider Demographics
NPI:1154690436
Name:RODRIGUEZ, DANE MATTHEW (CRNA)
Entity Type:Individual
Prefix:MR
First Name:DANE
Middle Name:MATTHEW
Last Name:RODRIGUEZ
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 1:8946 INTERLINE AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-1913
Mailing Address - Country:US
Mailing Address - Phone:225-923-0030
Mailing Address - Fax:225-923-0060
Practice Address - Street 1:6300 MAIN ST
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-4037
Practice Address - Country:US
Practice Address - Phone:225-658-4337
Practice Address - Fax:225-658-4181
Is Sole Proprietor?:No
Enumeration Date:2011-12-15
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA121003163W00000X
LA1210036736367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2182081Medicaid
MS07674505Medicaid
LA342418YH3UMedicare PIN