Provider Demographics
NPI:1144778283
Name:GUEDRY, ALEXANDRA THERIOT (PA-C)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:THERIOT
Last Name:GUEDRY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALEXANDRA
Other - Middle Name:RAE
Other - Last Name:THERIOT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:7777 HENNESSY BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4363
Mailing Address - Country:US
Mailing Address - Phone:225-767-6700
Mailing Address - Fax:225-767-6721
Practice Address - Street 1:7777 HENNESSY BLVD STE 103
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4363
Practice Address - Country:US
Practice Address - Phone:225-767-6700
Practice Address - Fax:225-767-6721
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-19
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA303837363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2430319Medicaid