Provider Demographics
NPI:1154015329
Name:PETERSON, LAQUINTEN (NP)
Entity type:Individual
Prefix:
First Name:LAQUINTEN
Middle Name:
Last Name:PETERSON
Suffix:
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 293
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71221-0293
Mailing Address - Country:US
Mailing Address - Phone:318-283-3910
Mailing Address - Fax:318-239-8910
Practice Address - Street 1:323 W WALNUT AVE
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-4521
Practice Address - Country:US
Practice Address - Phone:318-218-6077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-08
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA229719363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily