Provider Demographics
NPI:1871596981
Name:LASSETER, BRIAN ANDREW (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:ANDREW
Last Name:LASSETER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 NE JENSEN BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:JENSEN BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34957-7233
Mailing Address - Country:US
Mailing Address - Phone:772-334-1700
Mailing Address - Fax:772-334-1703
Practice Address - Street 1:1801 NE JENSEN BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JENSEN BEACH
Practice Address - State:FL
Practice Address - Zip Code:34957-7233
Practice Address - Country:US
Practice Address - Phone:772-334-1700
Practice Address - Fax:772-334-1703
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL33303207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL33303OtherSTATE LICENSE
35169Medicare ID - Type Unspecified
FLD21540Medicare UPIN