Provider Demographics
NPI:1770537136
Name:BREAUX, TIMOTHY GERALD JR (CRNA)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:GERALD
Last Name:BREAUX
Suffix:JR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1909
Mailing Address - Country:US
Mailing Address - Phone:800-242-1131
Mailing Address - Fax:517-787-4146
Practice Address - Street 1:2021 PERDIDO ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-1352
Practice Address - Country:US
Practice Address - Phone:504-903-3370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN085125367500000X
LAAP04031367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1153401Medicaid
LA1153401Medicaid
LA3A192CQ68Medicare PIN