Healthcare Provider Details

I. General information

NPI: 1114912938
Provider Name (Legal Business Name): LEO BRAZEAU PA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7056 MARINER BLVD
SPRING HILL FL
34609-1000
US

IV. Provider business mailing address

7056 MARINER BLVD
SPRING HILL FL
34609-1000
US

V. Phone/Fax

Practice location:
  • Phone: 352-597-5557
  • Fax: 352-597-0552
Mailing address:
  • Phone: 352-597-5557
  • Fax: 352-597-0552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1894
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: