Provider Demographics
NPI:1801433271
Name:COTTON, JUSTIN NICHOLAS
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:NICHOLAS
Last Name:COTTON
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 1:16018 SOMERSBY AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70817-6100
Mailing Address - Country:US
Mailing Address - Phone:225-888-5611
Mailing Address - Fax:
Practice Address - Street 1:16018 SOMERSBY AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70817-6100
Practice Address - Country:US
Practice Address - Phone:225-888-5611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-04
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
84-3847164343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA84-3847164Medicaid