Provider Demographics
NPI:1013674399
Name:LEONELLI, BERNARD THOMAS (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:BERNARD
Middle Name:THOMAS
Last Name:LEONELLI
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 W COLFAX AVE APT 427
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80204-2322
Mailing Address - Country:US
Mailing Address - Phone:219-671-1699
Mailing Address - Fax:
Practice Address - Street 1:490 W COLFAX AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-2607
Practice Address - Country:US
Practice Address - Phone:720-337-0200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-22
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0007201363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty