Provider Demographics
NPI:1295003267
Name:BISKUPOVICH, TRACI BOLSTER (NP)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:BOLSTER
Last Name:BISKUPOVICH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 LAPALCO BLVD
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70056-7336
Mailing Address - Country:US
Mailing Address - Phone:504-393-4376
Mailing Address - Fax:504-930-4307
Practice Address - Street 1:501 LAPALCO BLVD
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056-7336
Practice Address - Country:US
Practice Address - Phone:504-393-4376
Practice Address - Fax:504-930-4307
Is Sole Proprietor?:No
Enumeration Date:2011-12-06
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06648363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner