Provider Demographics
NPI:1619922481
Name:FUGAZY, LENNI (PA)
Entity Type:Individual
Prefix:MRS
First Name:LENNI
Middle Name:
Last Name:FUGAZY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041 WYOMI DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-2635
Mailing Address - Country:US
Mailing Address - Phone:239-321-9055
Mailing Address - Fax:
Practice Address - Street 1:1611 W HARRISON ST # 400
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4861
Practice Address - Country:US
Practice Address - Phone:312-243-4244
Practice Address - Fax:312-942-1517
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104242363A00000X
IL085002149363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1633878OtherBCBS PPO
ILP00990032OtherRR MEDICARE
FL292866300Medicaid
IL209118012Medicare PIN
FLP00449567Medicare PIN
IL1633878OtherBCBS PPO
FLAH292ZMedicare PIN