Provider Demographics
NPI:1841381647
Name:BRUNSON, CONNIE MARIE (PA)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:MARIE
Last Name:BRUNSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:MARIE
Other - Last Name:LAMBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:7777 HENNESSY BLVD
Mailing Address - Street 2:SUITE 406
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4300
Mailing Address - Country:US
Mailing Address - Phone:225-765-3456
Mailing Address - Fax:225-765-1899
Practice Address - Street 1:7777 HENNESSY BLVD STE 501B
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4300
Practice Address - Country:US
Practice Address - Phone:225-765-3456
Practice Address - Fax:225-765-1899
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200104.RX363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08623701Medicaid
LA1455261Medicaid
LA5CY57PC73Medicare PIN
MS08623701Medicaid