Provider Demographics
NPI:1205110756
Name:MELANCON, RENEE ROBICHAUX (PA)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:ROBICHAUX
Last Name:MELANCON
Suffix:
Gender:F
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:PO BOX 111
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70302-0111
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:810 E 3RD ST
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5728
Practice Address - Country:US
Practice Address - Phone:970-764-1790
Practice Address - Fax:970-375-7927
Is Sole Proprietor?:No
Enumeration Date:2011-10-03
Last Update Date:2021-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA200483363A00000X
COPA.0006273363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1445606Medicaid
LA2169815Medicaid
MS07779321Medicaid
5CG71Medicare UPIN
MS07779321Medicaid