Basic Information
| Provider Information | |||||||||
| NPI: | 1811322605 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THIBODEAUX | ||||||||
| FirstName: | MEREDITH | ||||||||
| MiddleName: | WADE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.A.-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WADE | ||||||||
| OtherFirstName: | MEREDITH | ||||||||
| OtherMiddleName: | ANN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 479 HOLOMON LOOP | ||||||||
| Address2: | |||||||||
| City: | DUBBERLY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 710242747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3185648781 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1541 KINGS HWY | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711034228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186754394 | ||||||||
| FaxNumber: | 3186756186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2013 | ||||||||
| LastUpdateDate: | 12/10/2015 | ||||||||
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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 | 200668 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2345290 | 05 | LA | MEDICAID |