Provider Demographics
NPI:1972116259
Name:CHUNG, LEEANNE VICTORIA (PA-C)
Entity Type:Individual
Prefix:
First Name:LEEANNE
Middle Name:VICTORIA
Last Name:CHUNG
Suffix:
Gender:F
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 1:640 LONDON RD
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:10598-2513
Mailing Address - Country:US
Mailing Address - Phone:914-629-6966
Mailing Address - Fax:
Practice Address - Street 1:1275 YORK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-6007
Practice Address - Country:US
Practice Address - Phone:914-629-6966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024810-01363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant