Provider Demographics
NPI:1104825371
Name:COMEAUX, JASON R (PA-C)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:R
Last Name:COMEAUX
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3438 TANNER RD
Mailing Address - Street 2:
Mailing Address - City:SCOTT
Mailing Address - State:LA
Mailing Address - Zip Code:70583-4011
Mailing Address - Country:US
Mailing Address - Phone:337-693-9999
Mailing Address - Fax:
Practice Address - Street 1:935 CAMELLIA BLVD
Practice Address - Street 2:STE 103
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-7084
Practice Address - Country:US
Practice Address - Phone:337-534-4356
Practice Address - Fax:337-534-4357
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA10608RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS970000044Medicare ID - Type Unspecified
MSQ20560Medicare UPIN