Healthcare Provider Details

I. General information

NPI: 1730197047
Provider Name (Legal Business Name): JESSE RAYMOND LECLAIR PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 FREEDOM WAY VAMC-DD, THORACIC SURGERY, ROUTING # 22
AUGUSTA GA
30904-6258
US

IV. Provider business mailing address

460 ASHRIDGE WAY
AUGUSTA GA
30907-4916
US

V. Phone/Fax

Practice location:
  • Phone: 706-733-0188
  • Fax: 706-823-3983
Mailing address:
  • Phone: 706-860-3753
  • Fax: 706-823-3983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number002936
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: