Provider Demographics
NPI:1689771776
Name:PATTERSON, PEPPER (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:PEPPER
Middle Name:
Last Name:PATTERSON
Suffix:
Gender:F
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:P O BOX 5310
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71135
Mailing Address - Country:US
Mailing Address - Phone:318-675-5584
Mailing Address - Fax:318-675-6681
Practice Address - Street 1:1501 KINGS HIGHWAY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-675-5581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP04403367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1478504Medicaid
TX190679401Medicaid
LA1478504Medicaid
LA4H536F699Medicare PIN