Provider Demographics
NPI:1710207725
Name:SMITH, BRENT LEE (ANP)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:M
Credentials:ANP
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 4176
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70361-4176
Mailing Address - Country:US
Mailing Address - Phone:985-872-5864
Mailing Address - Fax:985-872-0317
Practice Address - Street 1:2730 AMBASSADOR CAFFERY PKWY
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-5939
Practice Address - Country:US
Practice Address - Phone:337-988-1585
Practice Address - Fax:337-981-4694
Is Sole Proprietor?:No
Enumeration Date:2010-06-02
Last Update Date:2011-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN087084 - AP06269363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2142607Medicaid
LA3C1186833Medicare PIN