Provider Demographics
NPI:1508261322
Name:LEBLANC, KEONNA J
Entity Type:Individual
Prefix:
First Name:KEONNA
Middle Name:J
Last Name:LEBLANC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11920 ASTORIA BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77089-6097
Mailing Address - Country:US
Mailing Address - Phone:281-922-0400
Mailing Address - Fax:281-922-7040
Practice Address - Street 1:11920 ASTORIA BLVD
Practice Address - Street 2:SUITE 130
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77089-6097
Practice Address - Country:US
Practice Address - Phone:281-922-0400
Practice Address - Fax:281-922-7040
Is Sole Proprietor?:No
Enumeration Date:2014-10-23
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA09302363A00000X
LA200758363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant