Provider Demographics
NPI:1982857579
Name:LE GALL, JEAN BERNARD (PA)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:BERNARD
Last Name:LE GALL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 17567
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32522-7567
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:190 E. INTENDENCIA STREET
Practice Address - Street 2:SUITE A-28
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32502-5806
Practice Address - Country:US
Practice Address - Phone:850-908-6810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
FLPA9111202363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0249870000Medicaid