Provider Demographics
NPI:1679095863
Name:ODUM BRYANT, DEBORAH NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:NICOLE
Last Name:ODUM BRYANT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:NICOLE
Other - Last Name:ODUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:8000 W JUDGE PEREZ DR
Practice Address - Street 2:
Practice Address - City:CHALMETTE
Practice Address - State:LA
Practice Address - Zip Code:70043-1668
Practice Address - Country:US
Practice Address - Phone:504-826-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-10
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA305783363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2449583Medicaid