Provider Demographics
NPI:1811322605
Name:THIBODEAUX, MEREDITH WADE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MEREDITH
Middle Name:WADE
Last Name:THIBODEAUX
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MEREDITH
Other - Middle Name:ANN
Other - Last Name:WADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:479 HOLOMON LOOP
Mailing Address - Street 2:
Mailing Address - City:DUBBERLY
Mailing Address - State:LA
Mailing Address - Zip Code:71024-2747
Mailing Address - Country:US
Mailing Address - Phone:318-564-8781
Mailing Address - Fax:
Practice Address - Street 1:1541 KINGS HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-675-4394
Practice Address - Fax:318-675-6186
Is Sole Proprietor?:No
Enumeration Date:2013-09-11
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200668363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2345290Medicaid