Healthcare Provider Details

I. General information

NPI: 1710318597
Provider Name (Legal Business Name): EDWARD LEGARE RSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2013
Last Update Date: 09/17/2023
Certification Date: 09/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4656 LARKWOOD DR
VIRGINIA BEACH VA
23464-5817
US

IV. Provider business mailing address

4656 LARKWOOD DR
VIRGINIA BEACH VA
23464-5817
US

V. Phone/Fax

Practice location:
  • Phone: 757-353-9603
  • Fax:
Mailing address:
  • Phone: 757-353-9603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number0136000017
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: