Provider Demographics
NPI:1942638630
Name:LE BLANC-CABOT, MELETTE
Entity Type:Individual
Prefix:
First Name:MELETTE
Middle Name:
Last Name:LE BLANC-CABOT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1241 E DYER RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-5611
Mailing Address - Country:US
Mailing Address - Phone:888-306-0615
Mailing Address - Fax:
Practice Address - Street 1:1241 E DYER RD
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-5611
Practice Address - Country:US
Practice Address - Phone:888-306-0615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-16
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13691363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
XEHJ01812243OtherBLUE SHIELD