Provider Demographics
NPI:1245211341
Name:BURKSTALLER, MARIE ADELE (CRNA)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:ADELE
Last Name:BURKSTALLER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:ADELE
Other - Last Name:BERGERON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9103 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-2440
Mailing Address - Country:US
Mailing Address - Phone:225-927-1190
Mailing Address - Fax:225-706-0160
Practice Address - Street 1:9103 JEFFERSON HWY
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-2440
Practice Address - Country:US
Practice Address - Phone:225-927-1190
Practice Address - Fax:225-706-0160
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN06722367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1539775Medicaid
LAP00019003OtherRR MEDICARE
LAP00019003OtherRR MEDICARE