Provider Demographics
NPI:1679894646
Name:LASALA, BRANDIE (MD)
Entity type:Individual
Prefix:
First Name:BRANDIE
Middle Name:
Last Name:LASALA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26161 LA PAZ RD STE 115
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-5334
Mailing Address - Country:US
Mailing Address - Phone:717-531-8521
Mailing Address - Fax:
Practice Address - Street 1:26161 LA PAZ RD STE 115
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-5334
Practice Address - Country:US
Practice Address - Phone:949-206-0001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-14
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT198165208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics