Provider Demographics
NPI:1528166964
Name:INGVARDSEN, BRENT E (CRNA)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:E
Last Name:INGVARDSEN
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 1:511 DIXIE SWIM CLUB RD
Mailing Address - Street 2:
Mailing Address - City:STONEWALL
Mailing Address - State:LA
Mailing Address - Zip Code:71078-9538
Mailing Address - Country:US
Mailing Address - Phone:318-933-8201
Mailing Address - Fax:
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-675-5581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP04397367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1478407Medicaid
LA4H759Medicare ID - Type Unspecified