Basic Information
| Provider Information | |||||||||
| NPI: | 1841622636 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FUSILIER | ||||||||
| FirstName: | CAROLINE | ||||||||
| MiddleName: | BROWN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BROWN | ||||||||
| OtherFirstName: | CAROLINE | ||||||||
| OtherMiddleName: | N | ||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | DEPT AT952639 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 311922639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257657163 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5000 HENNESSY BLVD | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708084375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257657163 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2013 | ||||||||
| LastUpdateDate: | 04/18/2014 | ||||||||
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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 | 363AM0700X | PA.200639 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 2356143 | 05 | LA | MEDICAID |