Healthcare Provider Details

I. General information

NPI: 1710284872
Provider Name (Legal Business Name): JOSE RAMIL LASALA ACNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2011
Last Update Date: 07/21/2022
Certification Date: 07/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18101 OAKWOOD BLVD
DEARBORN MI
48124-4089
US

IV. Provider business mailing address

26901 BEAUMONT BLVD STE 3D
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 313-982-5440
  • Fax:
Mailing address:
  • Phone: 947-522-1863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number4704229984
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: