Provider Demographics
NPI:1588019509
Name:LAINA, LEONARDO (PA)
Entity Type:Individual
Prefix:
First Name:LEONARDO
Middle Name:
Last Name:LAINA
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 1:1625 NW 80TH AVE # A25
Mailing Address - Street 2:
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33063-9420
Mailing Address - Country:US
Mailing Address - Phone:954-600-3630
Mailing Address - Fax:
Practice Address - Street 1:7600 W CAMINO REAL STE 102
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-5514
Practice Address - Country:US
Practice Address - Phone:561-235-5206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109356363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant