Provider Demographics
NPI:1679518823
Name:LANDRY, MARK J (NP)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:J
Last Name:LANDRY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2851 JOHNSTON ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-3243
Mailing Address - Country:US
Mailing Address - Phone:337-456-3519
Mailing Address - Fax:337-534-4426
Practice Address - Street 1:3621 AMBASSADOR CAFFERY PKWY STE 100
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-5132
Practice Address - Country:US
Practice Address - Phone:337-534-4410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LARN095042207P00000X
LAAP04519363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1467430Medicaid
LA4H336CP33Medicare ID - Type Unspecified
LA1467430Medicaid