Provider Demographics
NPI:1609962612
Name:BROUSSARD, PAUL W (CRNA)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:W
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 1:2669 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-8700
Mailing Address - Country:US
Mailing Address - Phone:337-365-3168
Mailing Address - Fax:337-369-3536
Practice Address - Street 1:600 N LEWIS ST
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70560
Practice Address - Country:US
Practice Address - Phone:337-365-3168
Practice Address - Fax:337-369-3536
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA037524367500000X
NMCRNA-01145367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1696609Medicaid
LAP00131002Medicare PIN
LA5X418CH84Medicare PIN