Basic Information
| Provider Information | |||||||||
| NPI: | 1760748131 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | FRANCES | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2647 S SAINT ELIZABETH BLVD | ||||||||
| Address2: | GONZALES | ||||||||
| City: | GONZALES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707375021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256478511 | ||||||||
| FaxNumber: | 2256445213 | ||||||||
| Practice Location | |||||||||
| Address1: | 2647 S SAINT ELIZABETH BLVD | ||||||||
| Address2: | GONZALES | ||||||||
| City: | GONZALES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707375021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256478511 | ||||||||
| FaxNumber: | 2256445213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2012 | ||||||||
| LastUpdateDate: | 01/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA200693 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.