Laksamana Perintis Nusantara, NP

Primary specialty

Primary Care Nurse PractitionerTaxonomy code 363LP2300X

License

234786 Issued in LA

Practice address

401 Youngsville Hwy Ste 100
Lafayette, LA 70508-5173

Phone

(337) 451-0663

Fax

(337) 205-8650

NPI assigned

Aug 24, 2023

Reactivated

May 30, 2024

Sex

Male

Sole proprietor

No

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

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in LA

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

State licenses

Practice roles

Locations

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.

• Pediatric Group of Acadiana, LLC

  • Specialist
  • Lafayette, LA
  • NPI 1265499628
  Medicare reassignment NPD
• Pediatric Group of Acadiana LLC

  • Rural Health Clinic/Center
  • Kaplan, LA
  • NPI 1922619238
  NPD
• Pediatric Group of Acadiana, LLC

  • Rural Health Clinic/Center
  • Saint Martinville, LA
  • NPI 1922283225
  NPD

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

{
    "created_epoch": "1692835200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1761177600000",
    "number": "1205610607",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "401 YOUNGSVILLE HWY STE 100",
            "city": "LAFAYETTE",
            "state": "LA",
            "postal_code": "705085173",
            "telephone_number": "337-451-0663",
            "fax_number": "337-205-8650"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "401 YOUNGSVILLE HWY STE 100",
            "city": "LAFAYETTE",
            "state": "LA",
            "postal_code": "705085173",
            "telephone_number": "337-451-0663",
            "fax_number": "337-205-8650"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "NUSANTARA",
        "first_name": "LAKSAMANA",
        "middle_name": "PERINTIS",
        "credential": "NP",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2023-08-24",
        "last_updated": "2025-10-23",
        "certification_date": "2025-10-23",
        "deactivation_date": "2024-04-18",
        "reactivation_date": "2024-05-30",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "FL",
            "license": "11027192",
            "primary": false
        },
        {
            "code": "363LP2300X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Primary Care",
            "state": "LA",
            "license": "234786",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Nsi, Inc.
• Nucleonics of Acadiana, LLC
• Jency Broussard Nugier, PA-C
• Nurses Direct, L.L.C.
• Nurtured Heart, LLC
• Nydic Open MRI of America-Lafayette, LLC
• O E Reavill M D, Apmc
• Shelley Marks O'Brien, APRN
• Joshua Thompson O'Connor, LPC
• Robin O'Dell, FNP

• Primary Care Nurse Practitioner in Lafayette, LA
• Providers in Lafayette, LA by specialty
• Primary Care Nurse Practitioner in Louisiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 23, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.