Provider Demographics
NPI:1710514567
Name:PREJEAN, CODY JAMES
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:JAMES
Last Name:PREJEAN
Suffix:
Gender:M
Credentials:
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 6014
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70361-6014
Mailing Address - Country:US
Mailing Address - Phone:985-850-6398
Mailing Address - Fax:985-873-3789
Practice Address - Street 1:413 CAVANESS DR
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70364-2221
Practice Address - Country:US
Practice Address - Phone:985-859-6323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-23
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA220291367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA220291OtherLICENSE