Provider Demographics
NPI:1306878186
Name:VIAL, DONNA JEANNE (PA)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:JEANNE
Last Name:VIAL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6411 PERKINS RD STE 100
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4125
Mailing Address - Country:US
Mailing Address - Phone:225-303-9500
Mailing Address - Fax:
Practice Address - Street 1:1245 CAMELLIA BLVD STE 300
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-7219
Practice Address - Country:US
Practice Address - Phone:337-839-2773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA0000001234363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAPA.A10442OtherMEDICAL LICENSE
P72772Medicare UPIN