Provider Demographics
NPI:1740577998
Name:DAIGLE, JEFFREY JOHN (PA)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JOHN
Last Name:DAIGLE
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 1:501 DR MICHAEL DEBAKEY DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5724
Mailing Address - Country:US
Mailing Address - Phone:337-312-8258
Mailing Address - Fax:337-312-6708
Practice Address - Street 1:1615 WOLF CIR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-2348
Practice Address - Country:US
Practice Address - Phone:337-312-8681
Practice Address - Fax:337-312-8682
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA200462363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2161113Medicaid
LA57460PF37Medicare PIN
LA2161113Medicaid
LAP00981880Medicare PIN