Basic Information
| Provider Information | |||||||||
| NPI: | 1417504887 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LADOUCEUR | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 648 CRESTWOOD DRIVE | ||||||||
| Address2: | |||||||||
| City: | COVINGTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858052555 | ||||||||
| FaxNumber: | 9854005303 | ||||||||
| Practice Location | |||||||||
| Address1: | 648 CRESTWOOD DR | ||||||||
| Address2: | |||||||||
| City: | COVINGTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858052555 | ||||||||
| FaxNumber: | 9854005303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2019 | ||||||||
| LastUpdateDate: | 10/30/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SA2100X | 203735 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Acute Care |
No ID Information.