Provider Demographics
NPI:1346296027
Name:THERIOT, MATTHEW BLAINE (NP)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:BLAINE
Last Name:THERIOT
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2362 LARKSPUR LN
Mailing Address - Street 2:
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570-8674
Mailing Address - Country:US
Mailing Address - Phone:337-594-0675
Mailing Address - Fax:337-594-0850
Practice Address - Street 1:2362 LARKSPUR LN
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-8674
Practice Address - Country:US
Practice Address - Phone:337-594-0675
Practice Address - Fax:337-594-0850
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP04908363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1527408Medicaid
LA1527408Medicaid
LAQ69638Medicare UPIN