Healthcare Provider Details

I. General information

NPI: 1881145258
Provider Name (Legal Business Name): COREY DUPRE P.A.-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2016
Last Update Date: 10/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1990 INDUSTRIAL BLVD
HOUMA LA
70363-7055
US

IV. Provider business mailing address

1990 INDUSTRIAL BLVD
HOUMA LA
70363-7055
US

V. Phone/Fax

Practice location:
  • Phone: 985-850-1011
  • Fax: 985-851-0053
Mailing address:
  • Phone: 985-850-1011
  • Fax: 985-851-0053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number303639
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: