Provider Demographics
NPI:1750422440
Name:RICHARD SR, LEROY JOSEPH (PA)
Entity type:Individual
Prefix:MR
First Name:LEROY
Middle Name:JOSEPH
Last Name:RICHARD SR
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 CRESCENT LN
Mailing Address - Street 2:
Mailing Address - City:SUNSET
Mailing Address - State:LA
Mailing Address - Zip Code:70584-6115
Mailing Address - Country:US
Mailing Address - Phone:337-662-3063
Mailing Address - Fax:
Practice Address - Street 1:3305 W PINHOOK RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-3506
Practice Address - Country:US
Practice Address - Phone:337-233-4480
Practice Address - Fax:337-233-6334
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10186LA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant