Provider Demographics
NPI:1134844582
Name:LEON-POPOVYCH, ANDREA
Entity type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:
Last Name:LEON-POPOVYCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 BERGEN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07080-2703
Mailing Address - Country:US
Mailing Address - Phone:917-386-3500
Mailing Address - Fax:
Practice Address - Street 1:703 BERGEN ST
Practice Address - Street 2:
Practice Address - City:SOUTH PLAINFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07080-2703
Practice Address - Country:US
Practice Address - Phone:718-302-3704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-07
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01380200363LG0600X
NJAG08210071363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty