Provider Demographics
NPI:1164555769
Name:KOENCK, LEON (PA C)
Entity Type:Individual
Prefix:MR
First Name:LEON
Middle Name:
Last Name:KOENCK
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 WEST 34TH AVENUE
Mailing Address - Street 2:#539
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503
Mailing Address - Country:US
Mailing Address - Phone:888-300-0137
Mailing Address - Fax:888-300-0137
Practice Address - Street 1:46900 OCEAN DR
Practice Address - Street 2:STE 1100
Practice Address - City:GUALALA
Practice Address - State:CA
Practice Address - Zip Code:95445-8353
Practice Address - Country:US
Practice Address - Phone:707-884-4005
Practice Address - Fax:707-884-4625
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK270363A00000X
CAPA19714363A00000X, 363AM0700X
WAPA 10003212363A00000X
WAPA10003212363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S86261Medicare UPIN