Provider Demographics
NPI:1578810867
Name:LEONARD, GERALD
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:
Last Name:LEONARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5534 DRUID LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75209-5102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3865 CHILDRESS AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-2802
Practice Address - Country:US
Practice Address - Phone:972-681-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-06
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07832363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical