Provider Demographics
NPI:1679792014
Name:LORD, FRED A JR (CRNA)
Entity Type:Individual
Prefix:MR
First Name:FRED
Middle Name:A
Last Name:LORD
Suffix:JR
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 1:243 SCARLETT PVT DR
Mailing Address - Street 2:
Mailing Address - City:GLOSTER
Mailing Address - State:LA
Mailing Address - Zip Code:71030
Mailing Address - Country:US
Mailing Address - Phone:318-925-5826
Mailing Address - Fax:
Practice Address - Street 1:745 OLIVE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-2246
Practice Address - Country:US
Practice Address - Phone:318-227-1163
Practice Address - Fax:318-227-0413
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA033348367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1399370Medicaid
LA1399370Medicaid