Provider Demographics
NPI:1114116993
Name:PICCOLO, LELAND MATTHEW (PAC)
Entity Type:Individual
Prefix:MR
First Name:LELAND
Middle Name:MATTHEW
Last Name:PICCOLO
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:847 NE 19TH AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2684
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:9155 SW BARNES RD
Practice Address - Street 2:SUITE 440
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6625
Practice Address - Country:US
Practice Address - Phone:503-297-3766
Practice Address - Fax:503-297-8148
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORPA01395363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500604187Medicaid
WA1114116993Medicaid
OR500604187Medicaid
ORP01197009Medicare PIN