Provider Demographics
NPI:1396761060
Name:DETRAZ, DEIRDRE IRENE (ANPC)
Entity type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:IRENE
Last Name:DETRAZ
Suffix:
Gender:F
Credentials:ANPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 81095
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70598-1095
Mailing Address - Country:US
Mailing Address - Phone:337-739-7278
Mailing Address - Fax:337-989-7036
Practice Address - Street 1:207 N LUKE ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506
Practice Address - Country:US
Practice Address - Phone:337-739-7278
Practice Address - Fax:337-419-0533
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAPO 4805363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1031224Medicaid
LAQ72179Medicare UPIN
LA1031224Medicaid
LA4H943DB73Medicare PIN
LA4H943CA94Medicare PIN