Provider Demographics
NPI:1104806124
Name:MALLETT, CARL G (CRNA)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:G
Last Name:MALLETT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1128 HIDDEN OAK LN
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-7123
Mailing Address - Country:US
Mailing Address - Phone:337-478-1085
Mailing Address - Fax:
Practice Address - Street 1:1128 HIDDEN OAK LN
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-7123
Practice Address - Country:US
Practice Address - Phone:337-478-1085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA03828367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAP00140225OtherRAILROAD MEDICARE PIN
LA1115096Medicaid
LA1115096Medicaid