Provider Demographics
NPI:1699231308
Name:COLVON, DARTANYAN
Entity type:Individual
Prefix:
First Name:DARTANYAN
Middle Name:
Last Name:COLVON
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 1:337 SOMERSET ST
Mailing Address - Street 2:
Mailing Address - City:LA PLACE
Mailing Address - State:LA
Mailing Address - Zip Code:70068-5213
Mailing Address - Country:US
Mailing Address - Phone:504-994-8814
Mailing Address - Fax:
Practice Address - Street 1:337 SOMERSET ST
Practice Address - Street 2:
Practice Address - City:LA PLACE
Practice Address - State:LA
Practice Address - Zip Code:70068-5213
Practice Address - Country:US
Practice Address - Phone:504-994-8814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)