Provider Demographics
NPI:1003501057
Name:MEDLOCK, LEONA CAPEHART (PA-C)
Entity type:Individual
Prefix:
First Name:LEONA
Middle Name:CAPEHART
Last Name:MEDLOCK
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 1:5270 PEACHTREE PKWY STE 107
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CORNERS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-2558
Mailing Address - Country:US
Mailing Address - Phone:770-416-1070
Mailing Address - Fax:
Practice Address - Street 1:5270 PEACHTREE PKWY STE 107
Practice Address - Street 2:
Practice Address - City:PEACHTREE CORNERS
Practice Address - State:GA
Practice Address - Zip Code:30092-2558
Practice Address - Country:US
Practice Address - Phone:770-416-1070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-06
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA11077363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant