MEDICARE: DENNIS GEORGE LERIS PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	000103530	NC
2	363A00000X	Physician Assistant	103530	NC

General Provider Information

NPI Number	:	1629074323
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENNIS GEORGE LERIS PA-C

Provider Business Mailing Address
First Line	:	PO BOX 60447
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-0447
Country	:	US
Telephone Number	:	336-277-2225
Fax Number	:	336-277-2231

Provider Business Practice Location Address
First Line	:	190 KIMEL PARK DR STE 140
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-6946
Country	:	US
Telephone Number	:	336-277-2225
Fax Number	:	336-277-2231

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2005
Last Update Date	:	01/06/2020

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