Provider Demographics
NPI:1164022141
Name:PATTERSON, DESTRY QUADE (PTA)
Entity Type:Individual
Prefix:
First Name:DESTRY
Middle Name:QUADE
Last Name:PATTERSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2636 SOMERSET DR
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70131-5228
Mailing Address - Country:US
Mailing Address - Phone:504-206-9000
Mailing Address - Fax:
Practice Address - Street 1:1415 TULANE AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-2600
Practice Address - Country:US
Practice Address - Phone:504-988-5263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10739225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant