Basic Information
| Provider Information | |||||||||
| NPI: | 1164993432 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEDOUSSAUT | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | CHARLOTTE VALERI | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 CORPORATE BLVD | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705083870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008939698 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4300 ALTON RD | ||||||||
| Address2: | |||||||||
| City: | MIAMI BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331402948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054819776 | ||||||||
| FaxNumber: | 3056742007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2018 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
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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 | PAT9111939 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.