Provider Demographics
NPI:1710318597
Name:LEGARE, EDWARD (RSA)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:LEGARE
Suffix:
Gender:M
Credentials:RSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4656 LARKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-5817
Mailing Address - Country:US
Mailing Address - Phone:757-353-9603
Mailing Address - Fax:
Practice Address - Street 1:4656 LARKWOOD DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-5817
Practice Address - Country:US
Practice Address - Phone:757-353-9603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-04
Last Update Date:2023-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0136000017246ZC0007X
VA363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0136000017OtherREGISTERED SURGICAL ASSISTANT