Healthcare Provider Details

I. General information

NPI: 1912792185
Provider Name (Legal Business Name): NICHOLAS LEONARD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2025
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 BELLEVIEW AVE SE
ROANOKE VA
24014-1838
US

IV. Provider business mailing address

2705 WYCLIFFE AVE SW
ROANOKE VA
24014-2337
US

V. Phone/Fax

Practice location:
  • Phone: 540-525-5846
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0116042376
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: