Provider Demographics
NPI:1831202001
Name:LANDRY, TRAVIS J (PA)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:J
Last Name:LANDRY
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 1:602 N ACADIA RD
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-4847
Mailing Address - Country:US
Mailing Address - Phone:985-493-4727
Mailing Address - Fax:985-449-4603
Practice Address - Street 1:602 N ACADIA RD
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4847
Practice Address - Country:US
Practice Address - Phone:985-493-4727
Practice Address - Fax:985-449-4603
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA10521RX363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1023353Medicaid
LA57627P887Medicare PIN