Provider Demographics
NPI:1578755104
Name:BROUSSARD, NICHOLAS PAUL (CRNA)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:PAUL
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 1:5113 LA PREMIERE DR
Mailing Address - Street 2:
Mailing Address - City:MAURICE
Mailing Address - State:LA
Mailing Address - Zip Code:70555-3764
Mailing Address - Country:US
Mailing Address - Phone:337-278-0037
Mailing Address - Fax:
Practice Address - Street 1:5113 LA PREMIERE DR
Practice Address - Street 2:
Practice Address - City:MAURICE
Practice Address - State:LA
Practice Address - Zip Code:70555-3764
Practice Address - Country:US
Practice Address - Phone:337-278-0037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-17
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN108764163WC0200X
LAAP05366367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1315397Medicaid
LA3A753Medicare PIN