Healthcare Provider Details

I. General information

NPI: 1366058158
Provider Name (Legal Business Name): JONATHAN LEONG PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2020
Last Update Date: 09/17/2020
Certification Date: 09/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 3RD ST
ATWATER CA
95301-3608
US

IV. Provider business mailing address

220 12TH AVE
SAN FRANCISCO CA
94118-2104
US

V. Phone/Fax

Practice location:
  • Phone: 209-358-5611
  • Fax:
Mailing address:
  • Phone: 650-430-0081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number57762
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: