Basic Information
| Provider Information | |||||||||
| NPI: | 1407151913 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROUSSARD | ||||||||
| FirstName: | DUSTIN | ||||||||
| MiddleName: | COLE | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3185 | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712103185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3189986129 | ||||||||
| FaxNumber: | 3188121755 | ||||||||
| Practice Location | |||||||||
| Address1: | 312 GRAMMONT ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712017457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3189986129 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2011 | ||||||||
| LastUpdateDate: | 10/25/2017 | ||||||||
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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 | 367500000X | RN9306451 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | AP06688 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 125633 | 05 | AL | MEDICAID | P00924079 | 01 | RAILROAD MEDICARE | OTHER | 592-13560 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER | Y06R8 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 003203300 | 05 | FL | MEDICAID |