Provider Demographics
NPI:1629046586
Name:CLAYTON, DANIEL RAYDELL (PA)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:RAYDELL
Last Name:CLAYTON
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 1094
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70361-1094
Mailing Address - Country:US
Mailing Address - Phone:985-223-3132
Mailing Address - Fax:985-223-3126
Practice Address - Street 1:1022 BELANGER ST
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-4412
Practice Address - Country:US
Practice Address - Phone:985-223-3132
Practice Address - Fax:985-223-3126
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10531.RX363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1625922Medicaid
LA1625922Medicaid
LA56833P718Medicare PIN