Provider Demographics
NPI:1689136467
Name:RODRIGUEZ, LAZARO LUIS JR (PA-C)
Entity Type:Individual
Prefix:
First Name:LAZARO
Middle Name:LUIS
Last Name:RODRIGUEZ
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100905
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-0905
Mailing Address - Country:US
Mailing Address - Phone:954-392-1725
Mailing Address - Fax:
Practice Address - Street 1:1228 S PINE ISLAND RD STE 310
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-4583
Practice Address - Country:US
Practice Address - Phone:954-392-1725
Practice Address - Fax:954-837-1113
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-02
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113634363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty