Basic Information
Provider Information | |||||||||
NPI: | 1578896122 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BATSON | ||||||||
FirstName: | JERRY | ||||||||
MiddleName: | WILSON | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN, C-FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 103 ROBERTA DR | ||||||||
Address2: |   | ||||||||
City: | WEST MONROE | ||||||||
State: | LA | ||||||||
PostalCode: | 712912125 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3183960729 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 300 PAVILION RD | ||||||||
Address2: |   | ||||||||
City: | WEST MONROE | ||||||||
State: | LA | ||||||||
PostalCode: | 712929470 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3183231100 | ||||||||
FaxNumber: | 3183321161 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/15/2009 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP05917 | LA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 01729542 | 05 | MS |   | MEDICAID | 1808334 | 05 | LA |   | MEDICAID |