Basic Information
Provider Information | |||||||||
NPI: | 1245588300 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SEASONS PRIMARY CARE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1809 NORTHPOINTE LN | ||||||||
Address2: | SUITE 203 | ||||||||
City: | RUSTON | ||||||||
State: | LA | ||||||||
PostalCode: | 712703853 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3182557591 | ||||||||
FaxNumber: | 3182557584 | ||||||||
Practice Location | |||||||||
Address1: | 1809 NORTHPOINTE LN | ||||||||
Address2: | SUITE 203 | ||||||||
City: | RUSTON | ||||||||
State: | LA | ||||||||
PostalCode: | 712703853 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3182557591 | ||||||||
FaxNumber: | 3182557584 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/21/2012 | ||||||||
LastUpdateDate: | 08/21/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CASTON | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CO-OWNER | ||||||||
AuthorizedOfficialTelephone: | 3182557591 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SF0001X | AP06950 | LA | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Family Health |
ID Information
ID | Type | State | Issuer | Description | 094105 | 01 | LA | RN | OTHER | AP06950 | 01 | LA | NURSE PRACTITIONER | OTHER |