Provider Demographics
NPI:1063419745
Name:LEGROS, JIMMY III (NP)
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:
Last Name:LEGROS
Suffix:III
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 52453
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70505-2453
Mailing Address - Country:US
Mailing Address - Phone:337-942-8694
Mailing Address - Fax:337-942-8696
Practice Address - Street 1:3975 I 49 S SERVICE RD
Practice Address - Street 2:234
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-0775
Practice Address - Country:US
Practice Address - Phone:337-942-8694
Practice Address - Fax:337-942-8696
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN070188 - AP03265363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1541435Medicaid
LAP00387613Medicare PIN
LA4C621CF51Medicare PIN
LAP82963Medicare UPIN
LA4C621Medicare PIN