MEDICARE: LARRY LEYDERMAN PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	PA9114483	FL
2	363A00000X	Physician Assistant	PA9114483	FL
3	363AS0400X	Surgical Physician Assistant	085004191	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609143270
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARRY LEYDERMAN PA-C

Provider Business Mailing Address
First Line	:	1324 LAKELAND HILLS BLVD
Second Line	:	ATTN: MANAGED CARE DEPT
City	:	LAKELAND
State	:	FL
Zip	:	33805-4543
Country	:	US
Telephone Number	:	863-687-1100
Fax Number	:	863-630-6528

Provider Business Practice Location Address
First Line	:	13933 17TH ST STE 200
Second Line	:
City	:	DADE CITY
State	:	FL
Zip	:	33525-4604
Country	:	US
Telephone Number	:	352-437-5972
Fax Number	:	352-437-5974

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/25/2011
Last Update Date	:	12/01/2025

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