Provider Demographics
NPI:1407151913
Name:BROUSSARD, DUSTIN COLE (CRNA)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:COLE
Last Name:BROUSSARD
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:PO BOX 3185
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71210-3185
Mailing Address - Country:US
Mailing Address - Phone:318-998-6129
Mailing Address - Fax:318-812-1755
Practice Address - Street 1:312 GRAMMONT ST STE 100
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-7457
Practice Address - Country:US
Practice Address - Phone:318-998-6129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-13
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9306451367500000X
LAAP06688367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL125633Medicaid
P00924079OtherRAILROAD MEDICARE
AL592-13560OtherBLUE CROSS BLUE SHIELD
FLY06R8OtherBLUE CROSS BLUE SHIELD
FL003203300Medicaid
AL125633Medicaid