Provider Demographics
NPI:1932123221
Name:HEBERT, MARC THOMAS (PA)
Entity Type:Individual
Prefix:MR
First Name:MARC
Middle Name:THOMAS
Last Name:HEBERT
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 1:1747 IMPERIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-5362
Mailing Address - Country:US
Mailing Address - Phone:337-721-7236
Mailing Address - Fax:337-721-7237
Practice Address - Street 1:1747 IMPERIAL BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-5362
Practice Address - Country:US
Practice Address - Phone:337-721-7236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA200015363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5D847P624OtherMEDICARE LEGACY NUMBER
LAP02589614OtherRAILROAD MEDICARE
LA1812994Medicaid
LA5D847P624OtherMEDICARE LEGACY NUMBER
LAP00805730Medicare UPIN