Provider Demographics
NPI:1427155019
Name:CORMIER, GLENN (CRNA)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:CORMIER
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 1:2644 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:STE 121
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-2248
Mailing Address - Country:US
Mailing Address - Phone:225-293-2523
Mailing Address - Fax:225-293-1807
Practice Address - Street 1:8212 KELWOOD AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-4801
Practice Address - Country:US
Practice Address - Phone:225-929-7600
Practice Address - Fax:225-930-7524
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA036468367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1395242Medicaid
LA1395242Medicaid