Provider Demographics
NPI:1629077946
Name:CARPENTER, LEO (PA)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:
Last Name:CARPENTER
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:P.O. BOX 255228
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95865-5228
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:916-920-4434
Practice Address - Street 1:2800 L STREET
Practice Address - Street 2:#610
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5126
Practice Address - Country:US
Practice Address - Phone:916-731-4400
Practice Address - Fax:916-454-6926
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17424363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q30047Medicare UPIN
CA0PA174240Medicare ID - Type Unspecified