Provider Demographics
NPI:1871178194
Name:LASALA, GABRIELLE LAUREN (PA-C)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:LAUREN
Last Name:LASALA
Suffix:
Gender:F
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 1:6967 MAN O WAR LN
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-3448
Mailing Address - Country:US
Mailing Address - Phone:513-722-5945
Mailing Address - Fax:
Practice Address - Street 1:425 W GRAND AVE STE 1003
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-4776
Practice Address - Country:US
Practice Address - Phone:937-643-9299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-17
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH50.007182RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program