Provider Demographics
NPI:1598385502
Name:HYMAN, LEONIDA MATA
Entity Type:Individual
Prefix:
First Name:LEONIDA
Middle Name:MATA
Last Name:HYMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6103 POTOMAC ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92139-1730
Mailing Address - Country:US
Mailing Address - Phone:619-802-8879
Mailing Address - Fax:
Practice Address - Street 1:6103 POTOMAC ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92139-1730
Practice Address - Country:US
Practice Address - Phone:619-802-8879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB6150363OtherDRIVER LICENSE