Provider Demographics
NPI:1255886768
Name:BORDELON, GARY
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:BORDELON
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 1:3900 N CAUSEWAY BLVD # 625
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70002
Mailing Address - Country:US
Mailing Address - Phone:504-779-5515
Mailing Address - Fax:
Practice Address - Street 1:3900 N CAUSEWAY BLVD STE 625
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-1771
Practice Address - Country:US
Practice Address - Phone:504-779-5515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA128801367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered