Healthcare Provider Details

I. General information

NPI: 1104851633
Provider Name (Legal Business Name): LEONARD DELORENZO III PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 08/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 ALLEN ST
RUTLAND VT
05701-4560
US

IV. Provider business mailing address

160 ALLEN ST
RUTLAND VT
05701-4560
US

V. Phone/Fax

Practice location:
  • Phone: 802-747-1831
  • Fax: 802-747-1826
Mailing address:
  • Phone: 802-747-1831
  • Fax: 802-747-1826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9101620
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number055-0031054
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: