Provider Demographics
NPI:1104000231
Name:LEONARDO, MARISA ORENSE (RPAC)
Entity Type:Individual
Prefix:MS
First Name:MARISA
Middle Name:ORENSE
Last Name:LEONARDO
Suffix:
Gender:F
Credentials:RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:531 WINDSOR ST
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-5945
Mailing Address - Country:US
Mailing Address - Phone:516-334-5294
Mailing Address - Fax:
Practice Address - Street 1:71 METROPOLITAN OVAL
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462
Practice Address - Country:US
Practice Address - Phone:718-829-6436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-26
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012289-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0076TPMedicare PIN
NY092M699091Medicare PIN