Healthcare Provider Details

I. General information

NPI: 1750880134
Provider Name (Legal Business Name): ROBERT GOMANN GENOVESE II PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2018
Last Update Date: 02/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 WAYNE GILMORE CIR STE 250A
OPELOUSAS LA
70570-6405
US

IV. Provider business mailing address

3306 WALNUT DR
OPELOUSAS LA
70570-6946
US

V. Phone/Fax

Practice location:
  • Phone: 337-948-8556
  • Fax: 337-948-6881
Mailing address:
  • Phone: 337-945-4695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number307277
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: