Provider Demographics
NPI:1790759462
Name:FEGLEY, BRINTON J (NP)
Entity Type:Individual
Prefix:
First Name:BRINTON
Middle Name:J
Last Name:FEGLEY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 37388
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71133-7388
Mailing Address - Country:US
Mailing Address - Phone:318-631-6400
Mailing Address - Fax:318-631-0300
Practice Address - Street 1:2727 HEARNE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3931
Practice Address - Country:US
Practice Address - Phone:318-631-6400
Practice Address - Fax:318-631-0300
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LAAP04104363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1160016Medicaid
LA1160016Medicaid
P72061Medicare UPIN