Provider Demographics
NPI:1194770503
Name:LESSARD, THERESA M (PA)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:LESSARD
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:PO BOX 354034
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32135-4034
Mailing Address - Country:US
Mailing Address - Phone:386-864-9800
Mailing Address - Fax:
Practice Address - Street 1:145 CYPRESS POINT PKWY
Practice Address - Street 2:SUITE 105
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-8426
Practice Address - Country:US
Practice Address - Phone:386-864-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3189363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291049700Medicaid
FL291049700Medicaid
FLE4406WMedicare PIN