Provider Demographics
NPI:1205610607
Name:NUSANTARA, LAKSAMANA PERINTIS (NP)
Entity type:Individual
Prefix:
First Name:LAKSAMANA
Middle Name:PERINTIS
Last Name:NUSANTARA
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 CROWLEY RAYNE HWY
Mailing Address - Street 2:
Mailing Address - City:CROWLEY
Mailing Address - State:LA
Mailing Address - Zip Code:70526-8210
Mailing Address - Country:US
Mailing Address - Phone:337-250-4710
Mailing Address - Fax:
Practice Address - Street 1:1307 CROWLEY RAYNE HWY STE C
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:LA
Practice Address - Zip Code:70526-8210
Practice Address - Country:US
Practice Address - Phone:337-250-4710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-24
Last Update Date:2025-02-18
Deactivation Date:2024-04-18
Deactivation Code:
Reactivation Date:2024-05-30
Provider Licenses
StateLicense IDTaxonomies
FL11027192363LF0000X
LA234786363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily