Provider Demographics
NPI:1477841674
Name:GAUTREAUX, BENJAMIN BLAIR (CRNA)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:BLAIR
Last Name:GAUTREAUX
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 2668
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70404-2668
Mailing Address - Country:US
Mailing Address - Phone:985-230-2198
Mailing Address - Fax:985-230-2159
Practice Address - Street 1:15790 PAUL VEGA MD DR
Practice Address - Street 2:ANESTHESIA DEPARTMENT
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1434
Practice Address - Country:US
Practice Address - Phone:985-230-1682
Practice Address - Fax:985-230-1617
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06520367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2157809Medicaid
LAAP06520OtherCRNA LICENSE
LA2157809Medicaid