Healthcare Provider Details

I. General information

NPI: 1528403532
Provider Name (Legal Business Name): RICARDO JORGE SOUZA LEAO FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2013
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 WOODLAND DR
LANCASTER SC
29720-4707
US

IV. Provider business mailing address

104 WOODLAND DR
LANCASTER SC
29720-4707
US

V. Phone/Fax

Practice location:
  • Phone: 803-285-5441
  • Fax: 803-285-7509
Mailing address:
  • Phone: 803-285-5441
  • Fax: 803-285-7509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number18218
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number225875
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: