Provider Demographics
NPI:1760462782
Name:LABATUT, DWAYNE PAUL (NP)
Entity Type:Individual
Prefix:MR
First Name:DWAYNE
Middle Name:PAUL
Last Name:LABATUT
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-647-8511
Mailing Address - Fax:225-644-5415
Practice Address - Street 1:2647 S SAINT ELIZABETH BLVD STE 100
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-5019
Practice Address - Country:US
Practice Address - Phone:225-765-5500
Practice Address - Fax:225-341-8206
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LAAP04308363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1179957Medicaid
LA1179957Medicaid
LA4C764C921Medicare ID - Type Unspecified
LA232799OtherWELLCARE