Provider Demographics
NPI:1912539115
Name:THIBODEAUX, COLBY RYAN (FNP)
Entity Type:Individual
Prefix:MR
First Name:COLBY
Middle Name:RYAN
Last Name:THIBODEAUX
Suffix:
Gender:M
Credentials:FNP
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Mailing Address - Street 1:PO BOX 122165 DEPT 2165
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75312-2162
Mailing Address - Country:US
Mailing Address - Phone:337-494-2921
Mailing Address - Fax:337-494-6523
Practice Address - Street 1:4345 NELSON RD STE 101
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4183
Practice Address - Country:US
Practice Address - Phone:337-480-7942
Practice Address - Fax:337-480-7964
Is Sole Proprietor?:No
Enumeration Date:2020-02-06
Last Update Date:2022-04-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LA211814363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2571796Medicaid
LA2571796Medicaid