MEDICARE: ANGELA P LASALLE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	01047101	IN
2	207Q00000X	Family Medicine Physician	01047101A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588621619
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA P LASALLE MD

Provider Business Mailing Address
First Line	:	11109 PARKVIEW PLAZA DR # 117
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1701
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1234 E DUPONT RD STE 3
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1545
Country	:	US
Telephone Number	:	260-672-6590
Fax Number	:	260-672-6599

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2006
Last Update Date	:	10/10/2022

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Directions to “ ANGELA P LASALLE MD” Practice Location

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