Provider Demographics
NPI:1235109265
Name:FORD, MICHAEL D (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:FORD
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 1:424 W MCNEESE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-5547
Mailing Address - Country:US
Mailing Address - Phone:337-478-0511
Mailing Address - Fax:337-478-5644
Practice Address - Street 1:424 W MCNEESE ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-5547
Practice Address - Country:US
Practice Address - Phone:337-478-0511
Practice Address - Fax:337-478-5644
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN085525367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1563021Medicaid
LA430054687OtherRAILROAD MEDICARE PIN
LA4B335Medicare ID - Type Unspecified