Active NPI
Justin Bohannan, AG-ACNP
- Acute Care Nurse Practitioner
- Lake Charles, LA
National Provider Identifier
1124695408
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Acute Care Nurse Practitioner
- License
- 219004
- Practice address
- 2770 3Rd Ave Ste 350
Lake Charles, LA 70601-0404 - Phone
- (337) 494-2750
- Fax
- (337) 494-2760
- NPI assigned
- Jun 7, 2021
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Acute Care Nurse Practitioner | 363LA2100X | 219004 | LA | Primary |
Addresses
Primary practice location
2770 3Rd Ave Ste 350
Lake Charles, LA 70601-0404
Mailing address
PO Box 122309 Dept 2309
Dallas, TX 75312-0001
Phone (337) 494-2772
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 219004 | Other | LA | STATE LICENSE |
| 2560891 | Medicaid | LA |
Electronic endpoints 1
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| Direct Messaging Address | pulm@mmg.imed.phimailbox.com | Direct |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Nurse Practitioner
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1623024000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1643846400000",
"number": "1124695408",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 122309 DEPT 2309",
"city": "DALLAS",
"state": "TX",
"postal_code": "753120001",
"telephone_number": "337-494-2772",
"fax_number": "337-494-2928"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2770 3RD AVE STE 350",
"city": "LAKE CHARLES",
"state": "LA",
"postal_code": "706010404",
"telephone_number": "337-494-2750",
"fax_number": "337-494-2760"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BOHANNAN",
"first_name": "JUSTIN",
"credential": "AG-ACNP",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2021-06-07",
"last_updated": "2022-02-03",
"certification_date": "2022-02-03",
"status": "A"
},
"taxonomies": [
{
"code": "363LA2100X",
"taxonomy_group": "",
"desc": "Nurse Practitioner, Acute Care",
"state": "LA",
"license": "219004",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "STATE LICENSE",
"identifier": "219004",
"state": "LA"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "2560891",
"state": "LA"
}
],
"endpoints": [
{
"endpointType": "DIRECT",
"endpointTypeDescription": "Direct Messaging Address",
"endpoint": "pulm@mmg.imed.phimailbox.com",
"affiliation": "N",
"use": "DIRECT",
"useDescription": "Direct",
"contentType": "CSV",
"contentTypeDescription": "CSV",
"address_1": "1701 Oak Park Blvd",
"city": "Lake Charles",
"state": "LA",
"country_code": "US",
"postal_code": "706018911",
"country_name": "United States",
"address_type": "DOM"
}
],
"other_names": []
}Other providers in Lake Charles, LA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 3, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.