Provider Demographics
NPI:1841576477
Name:ROMERO, BROCK JUDE (APRN)
Entity Type:Individual
Prefix:MR
First Name:BROCK
Middle Name:JUDE
Last Name:ROMERO
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 SOUTH MAIN STREET
Mailing Address - Street 2:P.O. BOX 278
Mailing Address - City:LOREAUVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70552
Mailing Address - Country:US
Mailing Address - Phone:337-229-4214
Mailing Address - Fax:337-229-4065
Practice Address - Street 1:411 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:LOREAUVILLE
Practice Address - State:LA
Practice Address - Zip Code:70552
Practice Address - Country:US
Practice Address - Phone:337-229-4214
Practice Address - Fax:337-229-4065
Is Sole Proprietor?:No
Enumeration Date:2011-10-27
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06694363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2177149Medicaid