Provider Demographics
NPI:1881947190
Name:BEAULIEU, LEON (AA)
Entity type:Individual
Prefix:
First Name:LEON
Middle Name:
Last Name:BEAULIEU
Suffix:
Gender:M
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1613 NORTH HARRISON PARKWAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2853
Mailing Address - Country:US
Mailing Address - Phone:954-514-4793
Mailing Address - Fax:954-851-1746
Practice Address - Street 1:1613 N. HARRISON PARKWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-2853
Practice Address - Country:US
Practice Address - Phone:954-514-4793
Practice Address - Fax:954-851-1746
Is Sole Proprietor?:No
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAA149367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant