MEDICARE: CHARLES DANIEL MELANCON PA

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
1	363AS0400X	Surgical Physician Assistant	A10616	LA

General Provider Information

NPI Number	:	1619977881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES DANIEL MELANCON PA

Provider Business Mailing Address
First Line	:	1103 KALISTE SALOOM ROAD
Second Line	:	SUITE 102
City	:	LAFAYETTE
State	:	LA
Zip	:	70508-2636
Country	:	US
Telephone Number	:	337-234-5234
Fax Number	:	337-235-2121

Provider Business Practice Location Address
First Line	:	1103 KALISTE SALOOM ROAD
Second Line	:	SUITE 102
City	:	LAFAYETTE
State	:	LA
Zip	:	70508-2636
Country	:	US
Telephone Number	:	337-234-5234
Fax Number	:	337-235-2121

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2005
Last Update Date	:	02/05/2009

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