Provider Demographics
NPI:1013167550
Name:BRISTER, KEVIN G
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:G
Last Name:BRISTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15038 HIGHWAY 8
Mailing Address - Street 2:
Mailing Address - City:COLFAX
Mailing Address - State:LA
Mailing Address - Zip Code:71417-5080
Mailing Address - Country:US
Mailing Address - Phone:318-793-8896
Mailing Address - Fax:
Practice Address - Street 1:1444 PETERMAN DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3432
Practice Address - Country:US
Practice Address - Phone:318-442-5399
Practice Address - Fax:318-442-1586
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-20
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN080838163W00000X
LAAP05710367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1881180Medicaid
LA1881180Medicaid