Provider Demographics
NPI:1629547096
Name:TRAHAN, JEFFREY JOHN (PA)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JOHN
Last Name:TRAHAN
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 1:1701 S FIELDSPAN RD
Mailing Address - Street 2:
Mailing Address - City:DUSON
Mailing Address - State:LA
Mailing Address - Zip Code:70529-3711
Mailing Address - Country:US
Mailing Address - Phone:337-254-7868
Mailing Address - Fax:
Practice Address - Street 1:6703 AMBASSADOR CAFFERY PKWY # B
Practice Address - Street 2:
Practice Address - City:BROUSSARD
Practice Address - State:LA
Practice Address - Zip Code:70518-5283
Practice Address - Country:US
Practice Address - Phone:337-948-1766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA310714363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant