Provider Demographics
NPI:1215966387
Name:DOMINGUE, JODY NEAL
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:NEAL
Last Name:DOMINGUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15790 PAUL VEGA MD DRIVE
Mailing Address - Street 2:CREDENTIALING
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-3087
Mailing Address - Country:US
Mailing Address - Phone:985-345-2700
Mailing Address - Fax:985-230-6652
Practice Address - Street 1:15790 PAUL VEGA MD DR
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1434
Practice Address - Country:US
Practice Address - Phone:985-345-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP02656367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1678741Medicaid
430035514OtherRR MEDICARE NUMBER
430035514OtherRR MEDICARE NUMBER