Provider Demographics
NPI:1164468435
Name:BROUSSARD, SHANE T (PA)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:T
Last Name:BROUSSARD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 KALISTE SALOOM ROAD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-2920
Mailing Address - Country:US
Mailing Address - Phone:337-234-5234
Mailing Address - Fax:337-235-2121
Practice Address - Street 1:1103 KALISTE SALOOM ROAD
Practice Address - Street 2:SUITE 102
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-2920
Practice Address - Country:US
Practice Address - Phone:337-234-5234
Practice Address - Fax:337-235-2121
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10272363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5U977P751Medicare PIN
LA5DD85P997Medicare PIN
LAP00352985Medicare PIN
LA5U998P172Medicare PIN