Provider Demographics
NPI:1982113296
Name:LEGER, GABRIELLE LA PORTA (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:GABRIELLE
Middle Name:LA PORTA
Last Name:LEGER
Suffix:
Gender:F
Credentials:PA-C
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 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5437
Mailing Address - Country:US
Mailing Address - Phone:214-456-7000
Mailing Address - Fax:
Practice Address - Street 1:19450 DEERFIELD AVE STE 100
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-6821
Practice Address - Country:US
Practice Address - Phone:571-350-3668
Practice Address - Fax:703-729-2689
Is Sole Proprietor?:No
Enumeration Date:2017-09-29
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110006332363A00000X
363AM0700X
TXPA11542363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3771982-01Medicaid