Provider Demographics
NPI:1619341724
Name:LEDER, CARL WALLACE (PA-C)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:WALLACE
Last Name:LEDER
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:PO BOX 1121
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-0254
Mailing Address - Country:US
Mailing Address - Phone:541-672-2691
Mailing Address - Fax:833-299-8415
Practice Address - Street 1:621 W MADRONE ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3090
Practice Address - Country:US
Practice Address - Phone:541-672-2691
Practice Address - Fax:833-299-8415
Is Sole Proprietor?:No
Enumeration Date:2015-12-01
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA174113363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant