Basic Information
| Provider Information | |||||||||
| NPI: | 1053302745 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONNER | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | ANTHONY | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 DR MICHAEL DEBAKEY DR | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706015724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3373128360 | ||||||||
| FaxNumber: | 3373126711 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 DR MICHAEL DEBAKEY DR | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706015724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374338400 | ||||||||
| FaxNumber: | 3373126708 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 09/30/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN074867AP04422 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | LA6100258 | 01 | LA | TRICARE | OTHER | 1467821 | 05 | LA | MEDICAID |