Provider Demographics
NPI:1538490727
Name:MARDI GRAS ANESTHESIA,INC.
Entity Type:Organization
Organization Name:MARDI GRAS ANESTHESIA,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TROY
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:MELANCON
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:239-591-4357
Mailing Address - Street 1:9746 WILSHIRE LAKES BLVD
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-0752
Mailing Address - Country:US
Mailing Address - Phone:239-591-4357
Mailing Address - Fax:
Practice Address - Street 1:9746 WILSHIRE LAKES BLVD
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-0752
Practice Address - Country:US
Practice Address - Phone:239-591-4357
Practice Address - Fax:239-591-2445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-27
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9189562367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty