Provider Demographics
NPI:1467917187
Name:AYLETT, LEON ROSS III (AGPCNP)
Entity Type:Individual
Prefix:
First Name:LEON
Middle Name:ROSS
Last Name:AYLETT
Suffix:III
Gender:M
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10505 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:ISLAND CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97850-8484
Mailing Address - Country:US
Mailing Address - Phone:541-663-9008
Mailing Address - Fax:541-624-5454
Practice Address - Street 1:10505 W 1ST ST
Practice Address - Street 2:
Practice Address - City:ISLAND CITY
Practice Address - State:OR
Practice Address - Zip Code:97850-8484
Practice Address - Country:US
Practice Address - Phone:541-663-9008
Practice Address - Fax:541-624-5454
Is Sole Proprietor?:No
Enumeration Date:2019-02-06
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202208292NP-PP363L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner