MEDICARE: MS. MEEGAN LANDRY DOMANGUE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	A10604	LA
2	363A00000X	Physician Assistant	A10604	LA

General Provider Information

NPI Number	:	1023265022
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MEEGAN LANDRY DOMANGUE PA-C

Provider Business Mailing Address
First Line	:	PO BOX 98035
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70898
Country	:	US
Telephone Number	:	225-766-0050
Fax Number	:	225-766-1499

Provider Business Practice Location Address
First Line	:	7301 HENNESSY BLVD
Second Line	:	#200
City	:	BATON ROUGE
State	:	LA
Zip	:	70801
Country	:	US
Telephone Number	:	225-766-0050
Fax Number	:	225-766-1499

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2008
Last Update Date	:	06/17/2009

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