Provider Demographics
NPI:1174142046
Name:DENNIS, LEBRON (PA-C)
Entity type:Individual
Prefix:
First Name:LEBRON
Middle Name:
Last Name:DENNIS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1643 NW 136TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2857
Mailing Address - Country:US
Mailing Address - Phone:888-447-2362
Mailing Address - Fax:
Practice Address - Street 1:435 N 5TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-2157
Practice Address - Country:US
Practice Address - Phone:602-827-2450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-10
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8173363A00000X
AZ390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty