Provider Demographics
NPI:1043317456
Name:LASALLE, VINCENT A (PA-C)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:A
Last Name:LASALLE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LAFAYETTE MEDICAL
Mailing Address - Street 2:599 ROUTE 32 P O BOX 429
Mailing Address - City:HIGHLAND MILLS
Mailing Address - State:NY
Mailing Address - Zip Code:10930
Mailing Address - Country:US
Mailing Address - Phone:845-928-2550
Mailing Address - Fax:845-928-7228
Practice Address - Street 1:LAFAYETTE MEDICAL
Practice Address - Street 2:599 ROUTE 32
Practice Address - City:HIGHLAND MILLS
Practice Address - State:NY
Practice Address - Zip Code:10930
Practice Address - Country:US
Practice Address - Phone:845-928-2550
Practice Address - Fax:845-928-7228
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1004980363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical