Provider Demographics
NPI:1376587899
Name:LASALLE, GERARD V (MD)
Entity type:Individual
Prefix:
First Name:GERARD
Middle Name:V
Last Name:LASALLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1643 NW 136TH AVE.
Mailing Address - Street 2:BLDG: H, SUITE: 100 MSC 11607-0004
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323
Mailing Address - Country:US
Mailing Address - Phone:865-500-1856
Mailing Address - Fax:865-560-7110
Practice Address - Street 1:1141 BEACH DR E
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-4937
Practice Address - Country:US
Practice Address - Phone:360-895-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00017511207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0190073OtherLIWA
WA0170816OtherLIWA
WALA1174OtherBSWA
WALA8001OtherBSWA
WA2165LAOtherBSWA
WA8328601Medicaid
WA0170825OtherLIWA
WALA8001OtherBSWA
WA0170825OtherLIWA
WA0190073OtherLIWA
WAG8853913Medicare PIN