Provider Demographics
NPI:1104851633
Name:DELORENZO, LEONARD III (PA)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:
Last Name:DELORENZO
Suffix:III
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4560
Mailing Address - Country:US
Mailing Address - Phone:802-747-1831
Mailing Address - Fax:802-747-1826
Practice Address - Street 1:160 ALLEN ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4560
Practice Address - Country:US
Practice Address - Phone:802-747-1831
Practice Address - Fax:802-747-1826
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101620363A00000X
VT055-0031054363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291646100Medicaid
FLU1239ZMedicare PIN
FL291646100Medicaid