Provider Demographics
NPI:1811256241
Name:BORDELON, TRISHA B (CRNA)
Entity type:Individual
Prefix:
First Name:TRISHA
Middle Name:B
Last Name:BORDELON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TRISHA
Other - Middle Name:A
Other - Last Name:BONANNO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:255 WEST MICHIGAN AVENUE
Mailing Address - Street 2:P O BOX 1123
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49206-1123
Mailing Address - Country:US
Mailing Address - Phone:800-516-5315
Mailing Address - Fax:517-787-7365
Practice Address - Street 1:3510 N CAUSEWAY BLVD
Practice Address - Street 2:404
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-3531
Practice Address - Country:US
Practice Address - Phone:800-516-5315
Practice Address - Fax:517-787-7365
Is Sole Proprietor?:No
Enumeration Date:2012-05-04
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN115537367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered