Healthcare Provider Details

I. General information

NPI: 1740577998
Provider Name (Legal Business Name): JEFFREY JOHN DAIGLE P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2011
Last Update Date: 12/27/2019
Certification Date: 12/27/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 WOLF CIR
LAKE CHARLES LA
70605-2348
US

IV. Provider business mailing address

501 DR MICHAEL DEBAKEY DR
LAKE CHARLES LA
70601-5724
US

V. Phone/Fax

Practice location:
  • Phone: 337-312-8681
  • Fax: 337-312-8682
Mailing address:
  • Phone: 337-312-8258
  • Fax: 337-312-6708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA200462
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: