NPIMap

Shane T Broussard, P.A.

Individual provider Active NPI Physician Assistant · Lafayette, LA

NPI 1164468435 · NPPES record last updated Feb 3, 2009

Key facts

NPI
1164468435
Entity type
Individual (NPI type 1)
Primary specialty
Physician Assistant 363A00000X
License
A10272 (LA)
Practice address
1103 Kaliste Saloom Road
Suite 102
Lafayette, LA 70508-2920
Phone
(337) 234-5234
Fax
(337) 235-2121
NPI assigned
Jun 22, 2006
Sex
Male
Sole proprietor
No

Organizations & group practices 5

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Medicare participation

Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD)
Yes
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
A10272LAMDPhysician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Northstar Neurology LLC Past Accepting new patients
Acadiana Rehab Associates Inc a Professional Medical Corporation Past Accepting new patients
Louisiana Emergency Physicians, LLC Past Accepting new patients
Carolyn Y. Smith Past Accepting new patients
Norman E Anseman Jr MD, a Professional Medical Corporation Past Accepting new patients

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X A10272 LA Yes

Addresses

Primary practice location

1103 Kaliste Saloom Road
Suite 102
Lafayette, LA 70508-2920

Mailing address

1103 Kaliste Saloom Road
Suite 102
Lafayette, LA 70508-2920
Phone (337) 234-5234

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Feb 3, 2009.

{
    "created_epoch": "1150934400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1233619200000",
    "number": "1164468435",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1103 KALISTE SALOOM ROAD",
            "address_2": "SUITE 102",
            "city": "LAFAYETTE",
            "state": "LA",
            "postal_code": "705082920",
            "telephone_number": "337-234-5234",
            "fax_number": "337-235-2121"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1103 KALISTE SALOOM ROAD",
            "address_2": "SUITE 102",
            "city": "LAFAYETTE",
            "state": "LA",
            "postal_code": "705082920",
            "telephone_number": "337-234-5234",
            "fax_number": "337-235-2121"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BROUSSARD",
        "first_name": "SHANE",
        "middle_name": "T",
        "credential": "P.A.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-06-22",
        "last_updated": "2009-02-03",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "LA",
            "license": "A10272",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Lafayette, LA

All providers in Lafayette, LA · Physician Assistant in Louisiana

Sources for this page

Verify at the official NPI Registry.