Provider Demographics
NPI:1902894595
Name:THIBODEAUX, LARA CORNELIA (NP)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:CORNELIA
Last Name:THIBODEAUX
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LARA
Other - Middle Name:CORNELIA
Other - Last Name:BOYETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1500 UNIVERSITY DR E
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77840-2600
Mailing Address - Country:US
Mailing Address - Phone:979-846-1100
Mailing Address - Fax:979-260-9390
Practice Address - Street 1:808 W US HIGHWAY 79
Practice Address - Street 2:2880
Practice Address - City:FRANKLIN
Practice Address - State:TX
Practice Address - Zip Code:77856
Practice Address - Country:US
Practice Address - Phone:979-282-4540
Practice Address - Fax:979-828-3006
Is Sole Proprietor?:No
Enumeration Date:2005-10-08
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX593517363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1841562451OtherFACILITY NPI (SJHP FRANKLIN)
TX2952517-01OtherBVCAA DBA ST,. JOSEPH HEALTH POINT FRANKLIN MEDICAID (PTAN) NUMBER
TX67-1981OtherBVCAA DBA: ST. JOSEPH HEALTH POINT FRANKLIN PTAN (MEDICARE NUMBER)
TX67-1981OtherBVCAA DBA: ST. JOSEPH HEALTH POINT FRANKLIN PTAN (MEDICARE NUMBER)
TX74-1715140OtherBVCAA, INC. - TIN