Provider Demographics
NPI:1184701930
Name:VANDUZEE, ANTHONY LESLIE (PAC)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:LESLIE
Last Name:VANDUZEE
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5439 AIRLINE HWY
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70805-1712
Mailing Address - Country:US
Mailing Address - Phone:225-358-2280
Mailing Address - Fax:
Practice Address - Street 1:5439 AIRLINE HWY
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70805-1712
Practice Address - Country:US
Practice Address - Phone:225-358-2280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10412363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1453188Medicaid
LA5C822PF46Medicare PIN
LA1453188Medicaid