Provider Demographics
NPI:1205500907
Name:LEBIODA, CARLEY JEAN (PA)
Entity type:Individual
Prefix:
First Name:CARLEY
Middle Name:JEAN
Last Name:LEBIODA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3508 FAR WEST BLVD STE 130
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-3081
Mailing Address - Country:US
Mailing Address - Phone:512-293-6822
Mailing Address - Fax:
Practice Address - Street 1:3805 FAR WEST BLVD.
Practice Address - Street 2:SUITE 130
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731
Practice Address - Country:US
Practice Address - Phone:512-293-6822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-05
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIPENDING363A00000X
TXPA15868363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty