Provider Demographics
NPI:1174914626
Name:ISTRE, GARETT R (NP)
Entity type:Individual
Prefix:
First Name:GARETT
Middle Name:R
Last Name:ISTRE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 DR MICHAEL DEBAKEY DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5724
Mailing Address - Country:US
Mailing Address - Phone:337-312-8360
Mailing Address - Fax:
Practice Address - Street 1:1747 IMPERIAL BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-5362
Practice Address - Country:US
Practice Address - Phone:337-721-7236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-05
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP08181363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2383248Medicaid
LA412014YH5NMedicare PIN