NPIMap

Individual provider Active NPI

Shane T Broussard, P.A.

  • Physician Assistant
  • Lafayette, LA
National Provider Identifier
1164468435
Registry record updated Feb 3, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
A10272 Issued in 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
Last updated
Feb 3, 2009By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Feb 3, 2009

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

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

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

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
Physician Assistant

State licenses

LicenseStateTypeSpecialty
A10272LAMDPhysician Assistant

Practice roles

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

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, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "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

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 3, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.