Basic Information
| Provider Information | |||||||||
| NPI: | 1134452394 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROY | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ANGELLE | ||||||||
| OtherFirstName: | ANGELA | ||||||||
| OtherMiddleName: | C | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9001 SUMMA AVE | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708093726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257615200 | ||||||||
| FaxNumber: | 2257615558 | ||||||||
| Practice Location | |||||||||
| Address1: | 9001 SUMMA AVE | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708093726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257615200 | ||||||||
| FaxNumber: | 2257615558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2009 | ||||||||
| LastUpdateDate: | 10/28/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA200271 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1894125 | 05 | LA | MEDICAID | 03053256 | 05 | MS | MEDICAID |