Provider Demographics
NPI:1619977881
Name:MELANCON, CHARLES DANIEL (PA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DANIEL
Last Name:MELANCON
Suffix:
Gender:M
Credentials:PA
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Other - First Name:
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Mailing Address - Street 1:1103 KALISTE SALOOM ROAD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-2636
Mailing Address - Country:US
Mailing Address - Phone:337-234-5234
Mailing Address - Fax:337-235-2121
Practice Address - Street 1:1103 KALISTE SALOOM ROAD
Practice Address - Street 2:SUITE 102
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-2636
Practice Address - Country:US
Practice Address - Phone:337-234-5234
Practice Address - Fax:337-235-2121
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2009-02-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LAA10616363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5DD02P969Medicare PIN
LA54977P824Medicare PIN
Q20796Medicare UPIN