Provider Demographics
NPI:1811292394
Name:ROBERSON, BRENT STEVEN (CRNA)
Entity type:Individual
Prefix:MR
First Name:BRENT
Middle Name:STEVEN
Last Name:ROBERSON
Suffix:
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 1:11101 REIGER RD APT 515
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-0400
Mailing Address - Country:US
Mailing Address - Phone:985-232-8122
Mailing Address - Fax:
Practice Address - Street 1:7777 HENNESSY BLVD STE 709
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808
Practice Address - Country:US
Practice Address - Phone:985-232-8122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-14
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06385367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2146289Medicaid
LAP01813271OtherRAILROAD MEDICARE
LA2146289Medicaid