Provider Demographics
NPI:1114912938
Name:BRAZEAU, LEO (PA)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:
Last Name:BRAZEAU
Suffix:
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 1:7056 MARINER BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-1000
Mailing Address - Country:US
Mailing Address - Phone:352-597-5557
Mailing Address - Fax:352-597-0552
Practice Address - Street 1:7056 MARINER BLVD
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34609-1000
Practice Address - Country:US
Practice Address - Phone:352-597-5557
Practice Address - Fax:352-597-0552
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA1894363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S68419Medicare UPIN
FLE1685Medicare ID - Type Unspecified