Provider Demographics
NPI:1336465426
Name:LEONBERG, RYAN J (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:J
Last Name:LEONBERG
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 1:127 ONEIDA VALLEY RD STE 201
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:PA
Mailing Address - Zip Code:16001-2239
Mailing Address - Country:US
Mailing Address - Phone:724-431-4328
Mailing Address - Fax:724-431-2288
Practice Address - Street 1:127 ONEIDA VALLEY RD STE 202
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:PA
Practice Address - Zip Code:16001-2239
Practice Address - Country:US
Practice Address - Phone:724-282-4370
Practice Address - Fax:724-431-2288
Is Sole Proprietor?:No
Enumeration Date:2010-04-14
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4807363A00000X
PAMA054338363AS0400X
PA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1031437610001Medicaid