Provider Demographics
NPI:1679753222
Name:DAVID, BYRON BERNARD (NP)
Entity type:Individual
Prefix:
First Name:BYRON
Middle Name:BERNARD
Last Name:DAVID
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 83130
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70884-3130
Mailing Address - Country:US
Mailing Address - Phone:225-767-4893
Mailing Address - Fax:225-767-5494
Practice Address - Street 1:5131 ODONOVAN DR FL 1
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4782
Practice Address - Country:US
Practice Address - Phone:225-767-4893
Practice Address - Fax:225-767-5494
Is Sole Proprietor?:No
Enumeration Date:2007-11-13
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN076791 AP05330363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1022616Medicaid
LA3A468D279Medicare PIN