Provider Demographics
NPI:1952445249
Name:ACOSTA, BRYANT ANTHONY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRYANT
Middle Name:ANTHONY
Last Name:ACOSTA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 W LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:WINNFIELD
Mailing Address - State:LA
Mailing Address - Zip Code:71483-3463
Mailing Address - Country:US
Mailing Address - Phone:318-648-0375
Mailing Address - Fax:318-648-0378
Practice Address - Street 1:609 W COURT ST STE B
Practice Address - Street 2:
Practice Address - City:WINNFIELD
Practice Address - State:LA
Practice Address - Zip Code:71483-2686
Practice Address - Country:US
Practice Address - Phone:318-209-4646
Practice Address - Fax:318-209-4649
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPO835285146L00000X
LAPA.A10303.RX363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1452602Medicaid
LA1452602Medicaid