Provider Demographics
NPI:1356376065
Name:MANUEL, MARY MEAUX (PA)
Entity type:Individual
Prefix:MISS
First Name:MARY
Middle Name:MEAUX
Last Name:MANUEL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:516 VEROT SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-5026
Mailing Address - Country:US
Mailing Address - Phone:337-233-3850
Mailing Address - Fax:
Practice Address - Street 1:155 HOSPITAL DR
Practice Address - Street 2:SUITE 100
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2852
Practice Address - Country:US
Practice Address - Phone:337-235-7743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10536363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5C515P599Medicare ID - Type Unspecified