Provider Demographics
NPI:1669659363
Name:PAUL, TONY (PA)
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:
Last Name:PAUL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:130 JEFFERSON ST
Mailing Address - Street 2:P O BOX 740
Mailing Address - City:MANSFIELD
Mailing Address - State:LA
Mailing Address - Zip Code:71052-2602
Mailing Address - Country:US
Mailing Address - Phone:318-872-2700
Mailing Address - Fax:318-872-6214
Practice Address - Street 1:130 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:LA
Practice Address - Zip Code:71052-2602
Practice Address - Country:US
Practice Address - Phone:318-872-2700
Practice Address - Fax:318-872-6214
Is Sole Proprietor?:No
Enumeration Date:2008-01-24
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200164363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1365149Medicaid
LA1365149Medicaid