Basic Information
Provider Information | |||||||||
NPI: | 1205110756 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MELANCON | ||||||||
FirstName: | RENEE | ||||||||
MiddleName: | ROBICHAUX | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 111 | ||||||||
Address2: |   | ||||||||
City: | THIBODAUX | ||||||||
State: | LA | ||||||||
PostalCode: | 703020111 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 810 E 3RD ST | ||||||||
Address2: |   | ||||||||
City: | DURANGO | ||||||||
State: | CO | ||||||||
PostalCode: | 813015728 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9707641790 | ||||||||
FaxNumber: | 9703757927 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/03/2011 | ||||||||
LastUpdateDate: | 01/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA200483 | LA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363A00000X | PA.0006273 | CO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 1445606 | 05 | LA |   | MEDICAID | 2169815 | 05 | LA |   | MEDICAID | 07779321 | 05 | MS |   | MEDICAID |