Healthcare Provider Details

I. General information

NPI: 1043317456
Provider Name (Legal Business Name): VINCENT A LASALLE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LAFAYETTE MEDICAL 599 ROUTE 32
HIGHLAND MILLS NY
10930
US

IV. Provider business mailing address

LAFAYETTE MEDICAL 599 ROUTE 32 P O BOX 429
HIGHLAND MILLS NY
10930
US

V. Phone/Fax

Practice location:
  • Phone: 845-928-2550
  • Fax: 845-928-7228
Mailing address:
  • Phone: 845-928-2550
  • Fax: 845-928-7228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1004980
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: