Provider Demographics
NPI:1396045639
Name:PUETT, LEONARD ROBERT
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:ROBERT
Last Name:PUETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ROBERT
Other - Middle Name:
Other - Last Name:PUETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1148 BROADWAY STE 100
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-3518
Mailing Address - Country:US
Mailing Address - Phone:253-722-2161
Mailing Address - Fax:
Practice Address - Street 1:1148 BROADWAY STE 100
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-3518
Practice Address - Country:US
Practice Address - Phone:253-722-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-02
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60195245363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant