Provider Demographics
NPI:1437134707
Name:DOMINGUE, CAL ANTHONY (PA)
Entity Type:Individual
Prefix:
First Name:CAL
Middle Name:ANTHONY
Last Name:DOMINGUE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 54422
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70154-4422
Mailing Address - Country:US
Mailing Address - Phone:337-470-3580
Mailing Address - Fax:337-470-3586
Practice Address - Street 1:5000 AMBASSADOR CAFFERY PKWY BLDG 14A
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6984
Practice Address - Country:US
Practice Address - Phone:337-470-3580
Practice Address - Fax:337-470-3586
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10610363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1624861Medicaid
LAP00220721OtherRR MEDICARE
LAQ20797Medicare UPIN
LA56833P581Medicare PIN