Provider Demographics
NPI:1992796189
Name:BRISCOE, THOMAS L (PA-C)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:L
Last Name:BRISCOE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 MILL POND DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70592-5668
Mailing Address - Country:US
Mailing Address - Phone:337-241-9269
Mailing Address - Fax:
Practice Address - Street 1:1245 S COLLEGE RD BLDG 5
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2917
Practice Address - Country:US
Practice Address - Phone:337-235-6886
Practice Address - Fax:337-235-6892
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.015227183500000X
LAA10327363A00000X, 363AM0700X
LAA10327.RX363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No183500000XPharmacy Service ProvidersPharmacist
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1351016Medicaid
LA1351016Medicaid
LAS79331Medicare UPIN
LA53403P268Medicare ID - Type UnspecifiedPHYSICIAN ASSISTANT