Healthcare Provider Details

I. General information

NPI: 1437134707
Provider Name (Legal Business Name): CAL ANTHONY DOMINGUE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 12/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 AMBASSADOR CAFFERY PKWY BLDG 14A
LAFAYETTE LA
70508-6984
US

IV. Provider business mailing address

PO BOX 54422
NEW ORLEANS LA
70154-4422
US

V. Phone/Fax

Practice location:
  • Phone: 337-470-3580
  • Fax: 337-470-3586
Mailing address:
  • Phone: 337-470-3580
  • Fax: 337-470-3586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberA10610
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: