Provider Demographics
NPI:1891872214
Name:GAUTHREAUX, DANA BOUDREAUX (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:DANA
Middle Name:BOUDREAUX
Last Name:GAUTHREAUX
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 1:94 MASON ST
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70053-7040
Mailing Address - Country:US
Mailing Address - Phone:504-415-6242
Mailing Address - Fax:
Practice Address - Street 1:59213 RIVER WEST DR
Practice Address - Street 2:
Practice Address - City:PLAQUEMINE
Practice Address - State:LA
Practice Address - Zip Code:70764-6552
Practice Address - Country:US
Practice Address - Phone:225-687-2001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA200109363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical