Healthcare Provider Details

I. General information

NPI: 1871178194
Provider Name (Legal Business Name): GABRIELLE LAUREN LASALA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2021
Last Update Date: 02/10/2022
Certification Date: 02/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 W GRAND AVE STE 1003
DAYTON OH
45405-4776
US

IV. Provider business mailing address

6967 MAN O WAR LN
MASON OH
45040-3448
US

V. Phone/Fax

Practice location:
  • Phone: 937-643-9299
  • Fax:
Mailing address:
  • Phone: 513-722-5945
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.007182RX
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: