Healthcare Provider Details

I. General information

NPI: 1982724134
Provider Name (Legal Business Name): RICHARD LAWRENCE DELEZENE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 05/27/2025
Certification Date: 05/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 E VILLA MARIA RD STE A
BRYAN TX
77802-2583
US

IV. Provider business mailing address

2010 E VILLA MARIA RD STE A
BRYAN TX
77802-2583
US

V. Phone/Fax

Practice location:
  • Phone: 979-731-5200
  • Fax: 979-821-7631
Mailing address:
  • Phone: 979-731-5200
  • Fax: 979-821-7631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA05116
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: