Provider Demographics
NPI:1578523718
Name:BROUSSARD, KIM P (CRNA)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:P
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 1447
Mailing Address - Street 2:
Mailing Address - City:ABBEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70511-1447
Mailing Address - Country:US
Mailing Address - Phone:337-898-2803
Mailing Address - Fax:
Practice Address - Street 1:1101 S COLLEGE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-3038
Practice Address - Country:US
Practice Address - Phone:337-233-8603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN037148/AP02026367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1902764Medicaid
LA1902764Medicaid