Provider Demographics
NPI:1396307476
Name:CARMOUCHE, ANGELIQUE BLAIR (MAT, LAT,ATC)
Entity type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:BLAIR
Last Name:CARMOUCHE
Suffix:
Gender:F
Credentials:MAT, LAT,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LSU ATHLETIC ADMINISTRATION BUILDING
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70803-0001
Mailing Address - Country:US
Mailing Address - Phone:225-578-8001
Mailing Address - Fax:
Practice Address - Street 1:ASU STATION #10899
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76909-0001
Practice Address - Country:US
Practice Address - Phone:940-435-4347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-28
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3199662083S0010X
TXAT82582083S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine