Provider Demographics
NPI:1316778087
Name:SWANSON, PHILLIP JAMES
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:JAMES
Last Name:SWANSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39715 S HOOVER RD APT A
Mailing Address - Street 2:
Mailing Address - City:PONCHATOULA
Mailing Address - State:LA
Mailing Address - Zip Code:70454-4651
Mailing Address - Country:US
Mailing Address - Phone:662-848-9597
Mailing Address - Fax:
Practice Address - Street 1:15813 PAUL VEGA MD DR STE 401A
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1426
Practice Address - Country:US
Practice Address - Phone:985-230-1580
Practice Address - Fax:985-230-1585
Is Sole Proprietor?:No
Enumeration Date:2024-08-13
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA237082363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA237082OtherLICENSE