Basic Information
| Provider Information | |||||||||
| NPI: | 1578890190 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOODEAUX BROUSSARD | ||||||||
| FirstName: | JO | ||||||||
| MiddleName: | DEE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 108 RUE LOUIS XIV | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705085739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372358007 | ||||||||
| FaxNumber: | 8552705479 | ||||||||
| Practice Location | |||||||||
| Address1: | 108 RUE LOUIS XIV | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705085739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372358007 | ||||||||
| FaxNumber: | 8552705479 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2009 | ||||||||
| LastUpdateDate: | 10/06/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA200320 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1808181 | 05 | LA | MEDICAID |