Provider Demographics
NPI:1700867397
Name:CHARBONNEAU, LAVONNE M (PA-C)
Entity Type:Individual
Prefix:
First Name:LAVONNE
Middle Name:M
Last Name:CHARBONNEAU
Suffix:
Gender:F
Credentials:PA-C
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 699
Mailing Address - Street 2:114 NE 3RD ST
Mailing Address - City:ROLLA
Mailing Address - State:ND
Mailing Address - Zip Code:58367-0699
Mailing Address - Country:US
Mailing Address - Phone:701-477-3111
Mailing Address - Fax:701-477-6342
Practice Address - Street 1:114 3RD ST NE
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:ND
Practice Address - Zip Code:58367-7137
Practice Address - Country:US
Practice Address - Phone:701-477-3111
Practice Address - Fax:701-477-6342
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0002363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDS46449Medicare UPIN
ND15384Medicare ID - Type Unspecified