Basic Information
Provider Information | |||||||||
NPI: | 1174664080 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PASSOS | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | Q | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1103 KALISTE SALOOM RD | ||||||||
Address2: | SUITE 304 | ||||||||
City: | LAFAYETTE | ||||||||
State: | LA | ||||||||
PostalCode: | 705085783 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3379885646 | ||||||||
FaxNumber: | 3379884298 | ||||||||
Practice Location | |||||||||
Address1: | 1103 KALISTE SALOOM RD | ||||||||
Address2: | SUITE 304 | ||||||||
City: | LAFAYETTE | ||||||||
State: | LA | ||||||||
PostalCode: | 705085783 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3379885646 | ||||||||
FaxNumber: | 3379884298 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/12/2007 | ||||||||
LastUpdateDate: | 08/02/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN099257 | LA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 1408549 | 05 | LA |   | MEDICAID |