Provider Demographics
NPI:1003880956
Name:GOUDEAU, DUSTIN RAND (PAC)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:RAND
Last Name:GOUDEAU
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3351 MASONIC DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-3842
Mailing Address - Country:US
Mailing Address - Phone:318-473-9556
Mailing Address - Fax:318-441-8339
Practice Address - Street 1:3351 MASONIC DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3842
Practice Address - Country:US
Practice Address - Phone:318-473-9556
Practice Address - Fax:318-441-8339
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPAA10612363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAP00246919OtherRAILROAD MEDICARE PALMETT
LAP00246919OtherRAILROAD MEDICARE PALMETT
P96254Medicare UPIN