Provider Demographics
NPI:1538605027
Name:BROUSSARD, ANDREA
Entity type:Individual
Prefix:MR
First Name:ANDREA
Middle Name:
Last Name:BROUSSARD
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 1:406 PASS RD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-2901
Mailing Address - Country:US
Mailing Address - Phone:286-699-9840
Mailing Address - Fax:
Practice Address - Street 1:406 PASS RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507
Practice Address - Country:US
Practice Address - Phone:286-699-8402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-09
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
146D00000X, 172A00000X, 3747P1801X
MS374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
No172A00000XOther Service ProvidersDriver
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS104736701Medicaid
MS104736701Medicaid
MS104736701Medicare Oscar/Certification