Provider Demographics
NPI:1982087987
Name:PRESTIGE PRIMARY CARE PLLC
Entity Type:Organization
Organization Name:PRESTIGE PRIMARY CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:KATHERINE
Authorized Official - Last Name:TABOR
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:337-804-2049
Mailing Address - Street 1:2851 JOHNSTON ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-3243
Mailing Address - Country:US
Mailing Address - Phone:337-281-6102
Mailing Address - Fax:877-866-3181
Practice Address - Street 1:2851 JOHNSTON ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-3243
Practice Address - Country:US
Practice Address - Phone:337-281-6102
Practice Address - Fax:877-866-3181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP04615363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty