Provider Demographics
NPI:1861710923
Name:LETOURNEAU, JUSTIN FENNER (PA-C)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:FENNER
Last Name:LETOURNEAU
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2110 58TH ST W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-5660
Mailing Address - Country:US
Mailing Address - Phone:941-388-8997
Mailing Address - Fax:941-306-5876
Practice Address - Street 1:5565 DR MARTIN LUTHER KING JR ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33703-1203
Practice Address - Country:US
Practice Address - Phone:727-577-1203
Practice Address - Fax:727-577-0893
Is Sole Proprietor?:No
Enumeration Date:2010-05-13
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108503363AM0700X, 363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical