Provider Demographics
NPI:1730124595
Name:RAUCH, LEONARDO (PA-C)
Entity Type:Individual
Prefix:MR
First Name:LEONARDO
Middle Name:
Last Name:RAUCH
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 1:1515 N HARVARD AVE
Mailing Address - Street 2:STE E
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74115-4957
Mailing Address - Country:US
Mailing Address - Phone:918-832-6049
Mailing Address - Fax:918-832-6055
Practice Address - Street 1:1705 E 19TH ST
Practice Address - Street 2:STE 302
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5405
Practice Address - Country:US
Practice Address - Phone:918-748-7692
Practice Address - Fax:918-748-7539
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1733363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
000097248Medicare ID - Type Unspecified