Healthcare Provider Details

I. General information

NPI: 1659345502
Provider Name (Legal Business Name): ROBBIE BOYD MARCANTEL PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2006
Last Update Date: 01/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 NINTH ST
JENA LA
71342-3900
US

IV. Provider business mailing address

PO BOX 2780
JENA LA
71342-2780
US

V. Phone/Fax

Practice location:
  • Phone: 318-992-9268
  • Fax: 318-992-6201
Mailing address:
  • Phone: 318-992-9200
  • Fax: 318-992-9280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAA10386RX
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: