Provider Demographics
NPI:1275056418
Name:AGOMBAR WOLF, LEIGH (PA)
Entity Type:Individual
Prefix:
First Name:LEIGH
Middle Name:
Last Name:AGOMBAR WOLF
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LEIGH
Other - Middle Name:
Other - Last Name:AGOMBAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15728 S ROUTE 59
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-2693
Mailing Address - Country:US
Mailing Address - Phone:815-436-8831
Mailing Address - Fax:
Practice Address - Street 1:15728 S ROUTE 59
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60544-2693
Practice Address - Country:US
Practice Address - Phone:815-436-8831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-19
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006236363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant