Healthcare Provider Details

I. General information

NPI: 1760092688
Provider Name (Legal Business Name): KEOKI LAWRENCE GOEAS LEONG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2020
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4610 X ST
SACRAMENTO CA
95817-2200
US

IV. Provider business mailing address

1249 BERKSHIRE DR
PALMDALE CA
93551-4034
US

V. Phone/Fax

Practice location:
  • Phone: 916-734-2145
  • Fax:
Mailing address:
  • Phone: 702-285-4948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: