Basic Information
| Provider Information | |||||||||
| NPI: | 1124695408 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOHANNAN | ||||||||
| FirstName: | JUSTIN | ||||||||
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| Credential: | AG-ACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 122309 DEPT 2309 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753120001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374942772 | ||||||||
| FaxNumber: | 3374942928 | ||||||||
| Practice Location | |||||||||
| Address1: | 2770 3RD AVE STE 350 | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706010404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374942750 | ||||||||
| FaxNumber: | 3374942760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2021 | ||||||||
| LastUpdateDate: | 02/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 219004 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 219004 | 01 | LA | STATE LICENSE | OTHER | 2560891 | 05 | LA | MEDICAID |