Provider Demographics
NPI:1013777242
Name:WAX, GARRETT (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:GARRETT
Middle Name:
Last Name:WAX
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 BETZ AVE
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2412
Mailing Address - Country:US
Mailing Address - Phone:504-343-2986
Mailing Address - Fax:
Practice Address - Street 1:4228 HOUMA BLVD
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-3000
Practice Address - Country:US
Practice Address - Phone:504-454-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-22
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA234648363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care