Provider Demographics
NPI:1417068248
Name:DELEONARDO, JACK (PAC)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:DELEONARDO
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2699 S 167TH DR
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-7317
Mailing Address - Country:US
Mailing Address - Phone:406-927-2221
Mailing Address - Fax:
Practice Address - Street 1:650 E INDIAN SCHOOL RD
Practice Address - Street 2:DEPT VETERANS AFFAIRS
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012
Practice Address - Country:US
Practice Address - Phone:602-277-5551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT196363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0433296OtherMDCD PIN
MT092303OtherBCBS PIN
WY12355900OtherMDCD PIN
MT000081125Medicare PIN
MT000083517Medicare PIN
MT092303OtherBCBS PIN
MT0433296OtherMDCD PIN
MT970009866Medicare PIN