Provider Demographics
NPI:1538459599
Name:JAGOLINO, LEIANA LUTZ (PA)
Entity Type:Individual
Prefix:
First Name:LEIANA
Middle Name:LUTZ
Last Name:JAGOLINO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 RYAN DR SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-9687
Mailing Address - Country:US
Mailing Address - Phone:503-399-1262
Mailing Address - Fax:503-371-0777
Practice Address - Street 1:2925 RYAN DR SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-9687
Practice Address - Country:US
Practice Address - Phone:503-399-1262
Practice Address - Fax:503-371-0777
Is Sole Proprietor?:No
Enumeration Date:2011-04-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006077363A00000X
ORPA167677363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2044027Medicaid
GA003109002AMedicaid
OR500685132Medicaid
WA2044027Medicaid
GA202197867Medicare PIN