Provider Demographics
NPI:1558765875
Name:LEONARD, EVAN JAMES (PA-C)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:JAMES
Last Name:LEONARD
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 1:653 MONUMENT RD
Mailing Address - Street 2:APARTMENT 1512
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-6492
Mailing Address - Country:US
Mailing Address - Phone:727-253-7041
Mailing Address - Fax:
Practice Address - Street 1:851042 US HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097-2845
Practice Address - Country:US
Practice Address - Phone:904-633-0670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-15
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108342363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003173206AMedicaid
FL015527600Medicaid
FL015527600Medicaid
GA003173206AMedicaid
FLP01588102Medicare PIN