Provider Demographics
NPI:1235462813
Name:STOR, LEON (PA)
Entity Type:Individual
Prefix:
First Name:LEON
Middle Name:
Last Name:STOR
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11750 W 2ND PL
Mailing Address - Street 2:SUITE 255
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80228-1575
Mailing Address - Country:US
Mailing Address - Phone:720-321-8040
Mailing Address - Fax:720-321-8041
Practice Address - Street 1:11750 W 2ND PL
Practice Address - Street 2:SUITE 255
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-1575
Practice Address - Country:US
Practice Address - Phone:720-321-8040
Practice Address - Fax:720-321-8041
Is Sole Proprietor?:No
Enumeration Date:2009-09-14
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
363AM0700X
COPA-2907363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO91104530Medicaid
CO91104530Medicaid