Provider Demographics
NPI:1619112364
Name:DUFOUR, RONNIE BLISS (PA-C)
Entity Type:Individual
Prefix:
First Name:RONNIE
Middle Name:BLISS
Last Name:DUFOUR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:RONNIE
Other - Middle Name:BLISS
Other - Last Name:ARCENEAUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:7777 HENNESSY BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4300
Mailing Address - Country:US
Mailing Address - Phone:225-767-6700
Mailing Address - Fax:225-767-6721
Practice Address - Street 1:7777 HENNESSY BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4300
Practice Address - Country:US
Practice Address - Phone:225-767-6700
Practice Address - Fax:225-767-6721
Is Sole Proprietor?:No
Enumeration Date:2008-12-10
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200206363A00000X
LA200206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1360961Medicaid