Provider Demographics
NPI:1558601088
Name:CREDEUR, BRIAN JAMES (NP)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JAMES
Last Name:CREDEUR
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 1:501 DR MICHAEL DEBAKEY DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5724
Mailing Address - Country:US
Mailing Address - Phone:337-433-8400
Mailing Address - Fax:
Practice Address - Street 1:501 DR MICHAEL DEBAKEY DR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-5724
Practice Address - Country:US
Practice Address - Phone:337-312-8246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-20
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07219363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2327241Medicaid
LA2327241Medicaid
LA275625YH5NMedicare PIN