Provider Demographics
NPI:1073221917
Name:THIBODEAUX, BRENNAN JOSEPH (PA)
Entity Type:Individual
Prefix:MR
First Name:BRENNAN
Middle Name:JOSEPH
Last Name:THIBODEAUX
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:PO BOX 28
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70302-0028
Mailing Address - Country:US
Mailing Address - Phone:985-492-1203
Mailing Address - Fax:985-492-1203
Practice Address - Street 1:726 N ACADIA RD STE 1000
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-5051
Practice Address - Country:US
Practice Address - Phone:985-625-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA334149363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant