Provider Demographics
NPI:1013154061
Name:THIBODEAUX, RICHMOND SULLY (CRNA)
Entity type:Individual
Prefix:MR
First Name:RICHMOND
Middle Name:SULLY
Last Name:THIBODEAUX
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 MAUREEN DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70592-5817
Mailing Address - Country:US
Mailing Address - Phone:337-857-2750
Mailing Address - Fax:
Practice Address - Street 1:450 MEDICAL CENTER BLVD STE 520
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4229
Practice Address - Country:US
Practice Address - Phone:281-218-9515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-13
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120799367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered