Provider Demographics
NPI:1598724585
Name:CARBO, GLEN PAUL (FNP)
Entity Type:Individual
Prefix:MR
First Name:GLEN
Middle Name:PAUL
Last Name:CARBO
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 KALISTE SALOOM RD
Mailing Address - Street 2:STE 122
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-4230
Mailing Address - Country:US
Mailing Address - Phone:337-235-9355
Mailing Address - Fax:337-235-9356
Practice Address - Street 1:850 KALISTE SALOOM RD STE 122
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-4230
Practice Address - Country:US
Practice Address - Phone:337-235-9355
Practice Address - Fax:337-235-9356
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN086810 AP04260363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1163619Medicaid
LAP97258Medicare UPIN
LA1163619Medicaid