Provider Demographics
NPI:1881560829
Name:BLACK, GABRIELLE MIRE (PA)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:MIRE
Last Name:BLACK
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 1:3420 KIRK RD
Mailing Address - Street 2:
Mailing Address - City:MAURICE
Mailing Address - State:LA
Mailing Address - Zip Code:70555-3417
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4402 U S HIGHWAY 167
Practice Address - Street 2:
Practice Address - City:MAURICE
Practice Address - State:LA
Practice Address - Zip Code:70555-3708
Practice Address - Country:US
Practice Address - Phone:337-516-3110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-16
Last Update Date:2025-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA348969363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant