Provider Demographics
NPI:1407878622
Name:MOAK, LEON A (PA-C)
Entity Type:Individual
Prefix:MR
First Name:LEON
Middle Name:A
Last Name:MOAK
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 1:3484 E PAGE AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-4239
Mailing Address - Country:US
Mailing Address - Phone:602-320-5944
Mailing Address - Fax:
Practice Address - Street 1:475 S DOBSON RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5605
Practice Address - Country:US
Practice Address - Phone:480-963-4561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2562363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ623977Medicaid
AZZ78834Medicare ID - Type Unspecified
AZP43417Medicare UPIN