Healthcare Provider Details

I. General information

NPI: 1609143270
Provider Name (Legal Business Name): LARRY LEYDERMAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2011
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13933 17TH ST STE 200
DADE CITY FL
33525-4604
US

IV. Provider business mailing address

1324 LAKELAND HILLS BLVD ATTN: MANAGED CARE DEPT
LAKELAND FL
33805-4543
US

V. Phone/Fax

Practice location:
  • Phone: 352-437-5972
  • Fax: 352-437-5974
Mailing address:
  • Phone: 863-687-1100
  • Fax: 863-630-6528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9114483
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9114483
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number085004191
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: