Basic Information
| Provider Information | |||||||||
| NPI: | 1831518075 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FERGUSON | ||||||||
| FirstName: | ADAM | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7777 HENNESSY BLVD | ||||||||
| Address2: | ST. 701 | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708084300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257655864 | ||||||||
| FaxNumber: | 2257652013 | ||||||||
| Practice Location | |||||||||
| Address1: | 7777 HENNESSY BLVD | ||||||||
| Address2: | ST. 701 | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708084300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257655864 | ||||||||
| FaxNumber: | 2257652013 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2014 | ||||||||
| LastUpdateDate: | 12/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 200710 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 02739882 | 05 | MS | MEDICAID | 2368222 | 05 | LA | MEDICAID |