Provider Demographics
NPI:1619008018
Name:PUTNAM, PHILLIP L (CRNA)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:L
Last Name:PUTNAM
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 1:7777 HENNESSY BLVD
Mailing Address - Street 2:STE 301
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-0319
Mailing Address - Country:US
Mailing Address - Phone:225-769-4403
Mailing Address - Fax:225-769-3842
Practice Address - Street 1:8212 SUMMA AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3421
Practice Address - Country:US
Practice Address - Phone:225-769-4403
Practice Address - Fax:225-769-3842
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA069265 01565367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1692395Medicaid
LA1692395Medicaid