Healthcare Provider Details

I. General information

NPI: 1629176615
Provider Name (Legal Business Name): GARETT G GUILBEAU PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 04/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3704 NORTH BLVD SUITE C
ALEXANDRIA LA
71301-3658
US

IV. Provider business mailing address

3704 NORTH BLVD SUITE C
ALEXANDRIA LA
71301-3658
US

V. Phone/Fax

Practice location:
  • Phone: 318-443-4576
  • Fax: 318-449-5579
Mailing address:
  • Phone: 318-443-4576
  • Fax: 318-449-5579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1069238
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number200564
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: