Healthcare Provider Details

I. General information

NPI: 1669572947
Provider Name (Legal Business Name): BENJI JUNEAU PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 11/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 JOHN CIR
MONROE LA
71201-4508
US

IV. Provider business mailing address

1910 JOHN CIR
MONROE LA
71201-4508
US

V. Phone/Fax

Practice location:
  • Phone: 318-323-5446
  • Fax:
Mailing address:
  • Phone: 318-323-5446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.200086
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number16348
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: