Healthcare Provider Details

I. General information

NPI: 1154845808
Provider Name (Legal Business Name): COLLINS T KGOADI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2017
Last Update Date: 08/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2810 AMBASSADOR CAFFERY PKWY
LAFAYETTE LA
70506-5906
US

IV. Provider business mailing address

121 CRESTHILL DR
YOUNGSVILLE LA
70592-5656
US

V. Phone/Fax

Practice location:
  • Phone: 337-981-2949
  • Fax:
Mailing address:
  • Phone: 337-356-8834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number305550
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: