Basic Information
Provider Information | |||||||||
NPI: | 1013167550 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRISTER | ||||||||
FirstName: | KEVIN | ||||||||
MiddleName: | G | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 15038 HIGHWAY 8 | ||||||||
Address2: |   | ||||||||
City: | COLFAX | ||||||||
State: | LA | ||||||||
PostalCode: | 714175080 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3187938896 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1444 PETERMAN DR | ||||||||
Address2: |   | ||||||||
City: | ALEXANDRIA | ||||||||
State: | LA | ||||||||
PostalCode: | 713013432 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3184425399 | ||||||||
FaxNumber: | 3184421586 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2008 | ||||||||
LastUpdateDate: | 10/12/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN080838 | LA | N |   | Nursing Service Providers | Registered Nurse |   | 367500000X | AP05710 | LA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 1881180 | 05 | LA |   | MEDICAID |