Basic Information
| Provider Information | |||||||||
| NPI: | 1750592440 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCOMMON | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | ANGELA GARNET | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RIVERS | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | ANGELA GARNET | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 112 FOREST ST | ||||||||
| Address2: | |||||||||
| City: | PLAIN DEALING | ||||||||
| State: | LA | ||||||||
| PostalCode: | 710644031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183267272 | ||||||||
| FaxNumber: | 3183267282 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 N FORREST RD | ||||||||
| Address2: | |||||||||
| City: | PLAIN DEALING | ||||||||
| State: | LA | ||||||||
| PostalCode: | 710644031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183267272 | ||||||||
| FaxNumber: | 3183267282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 09/28/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD201547 | LA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1038130 | 05 | LA | MEDICAID | 1092452 | 05 | LA | MEDICAID | 1444286 | 05 | LA | MEDICAID | 2302639 | 05 | LA | MEDICAID |