Basic Information
| Provider Information | |||||||||
| NPI: | 1811256241 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BORDELON | ||||||||
| FirstName: | TRISHA | ||||||||
| MiddleName: | B. | ||||||||
| NamePrefix: | |||||||||
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| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BONANNO | ||||||||
| OtherFirstName: | TRISHA | ||||||||
| OtherMiddleName: | A. | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 255 WEST MICHIGAN AVENUE | ||||||||
| Address2: | P O BOX 1123 | ||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492061123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005165315 | ||||||||
| FaxNumber: | 5177877365 | ||||||||
| Practice Location | |||||||||
| Address1: | 3510 N CAUSEWAY BLVD | ||||||||
| Address2: | 404 | ||||||||
| City: | METAIRIE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700023531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005165315 | ||||||||
| FaxNumber: | 5177877365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2012 | ||||||||
| LastUpdateDate: | 11/07/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN115537 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.