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NPI Code Detail

MEDICARE: MR. JUSTIN FENNER LETOURNEAU PA-C

MEDICARE: MR. JUSTIN FENNER LETOURNEAU 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
1363AM0700XMedical Physician AssistantPA9108503FL
2363A00000XPhysician Assistant
3363A00000XPhysician AssistantPA9108503FL

General Provider Information

NPI Number : 1861710923
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. JUSTIN FENNER LETOURNEAU PA-C
Provider Business Mailing Address
First Line : 2110 58TH ST W
Second Line :
City : BRADENTON
State : FL
Zip : 34209-5660
Country : US
Telephone Number : 941-388-8997
Fax Number : 941-306-5876
Provider Business Practice Location Address
First Line : 5565 DR MARTIN LUTHER KING JR ST N
Second Line :
City : ST PETERSBURG
State : FL
Zip : 33703-1203
Country : US
Telephone Number : 727-577-1203
Fax Number : 727-577-0893
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/13/2010
Last Update Date : 06/30/2021

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