Provider Demographics
NPI:1578565339
Name:COLBURN, LEON QUINTON (PA)
Entity Type:Individual
Prefix:
First Name:LEON
Middle Name:QUINTON
Last Name:COLBURN
Suffix:
Gender:M
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:PO BOX 92900
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-0900
Mailing Address - Country:US
Mailing Address - Phone:503-261-4430
Mailing Address - Fax:
Practice Address - Street 1:10000 SE MAIN ST
Practice Address - Street 2:SUITE 365
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2448
Practice Address - Country:US
Practice Address - Phone:503-261-4430
Practice Address - Fax:503-261-4436
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00171363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500602877Medicaid
ORS22758Medicare UPIN
OR116064Medicare ID - Type UnspecifiedPORTLAND
OR500602877Medicaid