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NPI Code Detail

MEDICARE: DIMITRI NICHOLAS PAGOULATO PAC

MEDICARE: DIMITRI NICHOLAS PAGOULATO PAC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant200193LA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1194988915
Entity Type Code : Individual
Provider Name (Legal Business Name) : DIMITRI NICHOLAS PAGOULATO PAC
Provider Business Mailing Address
First Line : 5959 S SHERWOOD FOREST BLVD
Second Line :
City : BATON ROUGE
State : LA
Zip : 70816-6038
Country : US
Telephone Number : 225-774-7320
Fax Number : 225-765-9196
Provider Business Practice Location Address
First Line : 6516 E MYRTLE AVE
Second Line :
City : BAKER
State : LA
Zip : 70714-4348
Country : US
Telephone Number : 225-774-7320
Fax Number : 225-774-5432
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/02/2008
Last Update Date : 03/14/2025

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Directions to “ DIMITRI NICHOLAS PAGOULATO PAC” Practice Location

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