Provider Demographics
NPI:1356172340
Name:LA SALA, JESSE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JESSE
Middle Name:
Last Name:LA SALA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:JESSE
Other - Middle Name:
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:6465 MILLENNIUM STE 100
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-7831
Mailing Address - Country:US
Mailing Address - Phone:517-975-3720
Mailing Address - Fax:
Practice Address - Street 1:6465 MILLENNIUM STE 100
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-7831
Practice Address - Country:US
Practice Address - Phone:517-975-3720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-12
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant