Provider Demographics
NPI:1164407896
Name:CALDWELL, BERNIE M (PA-C)
Entity Type:Individual
Prefix:
First Name:BERNIE
Middle Name:M
Last Name:CALDWELL
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 1:10319 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-2730
Mailing Address - Country:US
Mailing Address - Phone:225-241-9935
Mailing Address - Fax:225-367-1060
Practice Address - Street 1:3424 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-7310
Practice Address - Country:US
Practice Address - Phone:318-450-4626
Practice Address - Fax:318-600-4078
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.A10383.RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P22321Medicare UPIN
LA5M343P353Medicare ID - Type Unspecified