Healthcare Provider Details

I. General information

NPI: 1376587899
Provider Name (Legal Business Name): GERARD V LASALLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 11/03/2023
Certification Date: 11/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1141 BEACH DR E
PORT ORCHARD WA
98366-4937
US

IV. Provider business mailing address

1643 NW 136TH AVE. BLDG: H, SUITE: 100 MSC 11607-0004
SUNRISE FL
33323
US

V. Phone/Fax

Practice location:
  • Phone: 360-895-4700
  • Fax:
Mailing address:
  • Phone: 865-500-1856
  • Fax: 865-560-7110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD00017511
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD00017511
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: