Provider Demographics
NPI:1750592440
Name:MCCOMMON, NICOLE ANGELA GARNET (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANGELA GARNET
Last Name:MCCOMMON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ANGELA GARNET
Other - Last Name:RIVERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:112 FOREST ST
Mailing Address - Street 2:
Mailing Address - City:PLAIN DEALING
Mailing Address - State:LA
Mailing Address - Zip Code:71064-4031
Mailing Address - Country:US
Mailing Address - Phone:318-326-7272
Mailing Address - Fax:318-326-7282
Practice Address - Street 1:112 N FORREST RD
Practice Address - Street 2:
Practice Address - City:PLAIN DEALING
Practice Address - State:LA
Practice Address - Zip Code:71064-4031
Practice Address - Country:US
Practice Address - Phone:318-326-7272
Practice Address - Fax:318-326-7282
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD201547207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1038130Medicaid
LA1092452Medicaid
LA1444286Medicaid
LA2302639Medicaid
LA193848Medicare PIN
LA4N015Medicare PIN