Provider Demographics
NPI:1619327087
Name:KESTERSON, DAVID R (PA-C)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:KESTERSON
Suffix:
Gender:M
Credentials:PA-C
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 5478
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70302-5478
Mailing Address - Country:US
Mailing Address - Phone:985-446-6284
Mailing Address - Fax:
Practice Address - Street 1:525 SAINT MARY ST
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-2627
Practice Address - Country:US
Practice Address - Phone:985-446-6284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA302525363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2423410Medicaid
LA511403YY46Medicare PIN