Provider Demographics
NPI:1043858152
Name:FUQUA, JUSTIN K (CRNA)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:K
Last Name:FUQUA
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 HENNESSY BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-0319
Mailing Address - Country:US
Mailing Address - Phone:225-214-6438
Mailing Address - Fax:
Practice Address - Street 1:5000 HENNESSY BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4375
Practice Address - Country:US
Practice Address - Phone:225-765-8541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-19
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024010874367500000X
PARN783971367500000X
LA210093367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered