Provider Demographics
NPI:1114518958
Name:LEAL MORELL, ROLANDO LAZARO
Entity Type:Individual
Prefix:
First Name:ROLANDO
Middle Name:LAZARO
Last Name:LEAL MORELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8239 MALVERN CIR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-2242
Mailing Address - Country:US
Mailing Address - Phone:813-325-4903
Mailing Address - Fax:
Practice Address - Street 1:8239 MALVERN CIR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-2242
Practice Address - Country:US
Practice Address - Phone:813-325-4903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11009703363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily