Provider Demographics
NPI:1609869452
Name:LOCKLEAR, REGINALD DEAN (PA)
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:DEAN
Last Name:LOCKLEAR
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 1:900 S PINE ISLAND RD STE 800
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3923
Mailing Address - Country:US
Mailing Address - Phone:305-940-6016
Mailing Address - Fax:305-940-6167
Practice Address - Street 1:1610 NE MIAMI GARDENS DR
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33179-4900
Practice Address - Country:US
Practice Address - Phone:305-940-6061
Practice Address - Fax:305-940-6167
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110529363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021847500Medicaid