Basic Information
| Provider Information | |||||||||
| NPI: | 1699712869 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | THALY | ||||||||
| FirstName: | LATA | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 72 LAKEWOOD ESTATES DR | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701318358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5042282077 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1978 INDUSTRIAL BLVD | ||||||||
| Address2: | LEONARD CHABERT MEDICAL CENTER | ||||||||
| City: | HOUMA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858732200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 10/04/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 14514 | LA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1325791 | 05 | LA | MEDICAID |