Basic Information
| Provider Information | |||||||||
| NPI: | 1861766206 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANDRY | ||||||||
| FirstName: | MATT | ||||||||
| MiddleName: | JUDE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4176 | ||||||||
| Address2: | |||||||||
| City: | HOUMA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703614176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858725864 | ||||||||
| FaxNumber: | 9858720317 | ||||||||
| Practice Location | |||||||||
| Address1: | 443 HEYMANN BLVD | ||||||||
| Address2: | STE. B | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705032630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372898429 | ||||||||
| FaxNumber: | 3372898431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2012 | ||||||||
| LastUpdateDate: | 03/15/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | AP06784 | LA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363L00000X | AP06784 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 2193601 | 05 | LA | MEDICAID |