Provider Demographics
NPI:1366447641
Name:LEONARDO, STEPHEN A (PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:A
Last Name:LEONARDO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:TONY
Other - Middle Name:
Other - Last Name:LEONARDO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:11790 SW BARNES RD STE 330
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5935
Mailing Address - Country:US
Mailing Address - Phone:503-228-4414
Mailing Address - Fax:503-228-7293
Practice Address - Street 1:2120 EXCHANGE ST STE 302
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3364
Practice Address - Country:US
Practice Address - Phone:503-338-2993
Practice Address - Fax:503-338-2996
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00900363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR231893Medicaid
OR381852OtherMEDICARE