Provider Demographics
NPI:1508440736
Name:LECLAIR, KARISSA LYNN (MD)
Entity type:Individual
Prefix:DR
First Name:KARISSA
Middle Name:LYNN
Last Name:LECLAIR
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 1:1430 FREEDOM BLVD
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-2780
Mailing Address - Country:US
Mailing Address - Phone:831-763-8400
Mailing Address - Fax:
Practice Address - Street 1:1430 FREEDOM BLVD
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-2780
Practice Address - Country:US
Practice Address - Phone:831-763-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-12
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351047781390200000X
CAA192494207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine