Basic Information
| Provider Information | |||||||||
| NPI: | 1881077808 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEASON | ||||||||
| FirstName: | CLEO | ||||||||
| MiddleName: | 'TREY' | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 DESIARD ST | ||||||||
| Address2: | SUITE 355 | ||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712017319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188077875 | ||||||||
| FaxNumber: | 3188126603 | ||||||||
| Practice Location | |||||||||
| Address1: | 2408 BROADMOOR BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712012994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188070525 | ||||||||
| FaxNumber: | 3188071077 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2015 | ||||||||
| LastUpdateDate: | 09/12/2016 | ||||||||
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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 | 363LF0000X | 08285 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 2398938 | 05 | LA | MEDICAID |