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General NPI Number Information
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NPI Number | 1609143270
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Entity Type | Individual
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Provider Name | LARRY LEYDERMAN PA-C
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Gender | Male
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Dates
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Enumeration Date | 11/25/2011
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Last Update Date | 12/01/2025
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Provider Practice Location Address
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Address Line | 13933 17TH ST STE 200
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City | DADE CITY
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State | FL
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Zip | 33525-4604
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Country | US
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Telephone | 352-437-5972
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Fax | 352-437-5974
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Provider Business Mailing Address
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Address Line | 1324 LAKELAND HILLS BLVD ATTN: MANAGED CARE DEPT
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City | LAKELAND
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State | FL
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Zip | 33805-4543
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Country | US
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Telephone | 863-687-1100
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Fax | 863-630-6528
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | PA9114483
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA9114483
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 085004191
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License Number State | IL
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