Basic Information
| Provider Information | |||||||||
| NPI: | 1982938866 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STAFFORD | ||||||||
| FirstName: | EVA | ||||||||
| MiddleName: | MARINA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5959 S SHERWOOD FOREST BLVD | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708166038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257655727 | ||||||||
| FaxNumber: | 2257659196 | ||||||||
| Practice Location | |||||||||
| Address1: | 8119 PICARDY AVE | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708093515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257655500 | ||||||||
| FaxNumber: | 2252143639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2009 | ||||||||
| LastUpdateDate: | 04/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | AP05813 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 1811122 | 05 | LA | MEDICAID |