Provider Demographics
NPI:1104719137
Name:LAZO, ANDREW JESUS
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:JESUS
Last Name:LAZO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 S CORTEZ AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708-2945
Mailing Address - Country:US
Mailing Address - Phone:305-804-4761
Mailing Address - Fax:
Practice Address - Street 1:5449 S SEMORAN BLVD STE 20
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-1778
Practice Address - Country:US
Practice Address - Phone:407-734-1273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-29
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11039812363LF0000X, 363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty