Basic Information
| Provider Information | |||||||||
| NPI: | 1982915195 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIXON | ||||||||
| FirstName: | TARISHA | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8490 PICARDY AVE | ||||||||
| Address2: | BLDG 200 | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708093731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252371754 | ||||||||
| FaxNumber: | 2252371722 | ||||||||
| Practice Location | |||||||||
| Address1: | 3401 NORTH BLVD | ||||||||
| Address2: | STE 200-A | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708063743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2253870851 | ||||||||
| FaxNumber: | 2253838477 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2010 | ||||||||
| LastUpdateDate: | 09/24/2014 | ||||||||
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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 | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | MD.205942 | LA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 295588YNB7 | 01 | LA | MEDICARE PTAN | OTHER | 2110454 | 05 | LA | MEDICAID |