Healthcare Provider Details

I. General information

NPI: 1659290658
Provider Name (Legal Business Name): EDER ADRIAN LEYVA VELAZQUEZ PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 COFFEE RD
MODESTO CA
95355-2803
US

IV. Provider business mailing address

5960 S LAND PARK DR # 1186
SACRAMENTO CA
95822-3313
US

V. Phone/Fax

Practice location:
  • Phone: 209-526-4500
  • Fax:
Mailing address:
  • Phone: 916-426-8220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA68330
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: