Basic Information
Provider Information | |||||||||
NPI: | 1831207398 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FIRMIN | ||||||||
FirstName: | KRISTIE | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | TUCKER | ||||||||
OtherFirstName: | KRISTIE | ||||||||
OtherMiddleName: | LEE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 8888 SUMMA AVE | ||||||||
Address2: | CARDIOLOGY TOWER 3RD FLOOR | ||||||||
City: | BATON ROUGE | ||||||||
State: | LA | ||||||||
PostalCode: | 708093720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2257694493 | ||||||||
FaxNumber: | 2257663144 | ||||||||
Practice Location | |||||||||
Address1: | 8888 SUMMA AVE | ||||||||
Address2: | CARDIOLOGY TOWER 3RD FLOOR | ||||||||
City: | BATON ROUGE | ||||||||
State: | LA | ||||||||
PostalCode: | 708093720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2257694493 | ||||||||
FaxNumber: | 2257663144 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/26/2006 | ||||||||
LastUpdateDate: | 12/16/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | A10534RX | LA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
ID | Type | State | Issuer | Description | 1626015 | 05 | LA |   | MEDICAID |