Provider Demographics
NPI:1255391793
Name:LEINWAND, MARK HENRY (PA-C)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:HENRY
Last Name:LEINWAND
Suffix:
Gender:M
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 1:13 NORTH FULTON STREET
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021
Mailing Address - Country:US
Mailing Address - Phone:315-255-1171
Mailing Address - Fax:315-252-7801
Practice Address - Street 1:13 NORTH FULTON STREET
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021
Practice Address - Country:US
Practice Address - Phone:315-255-1171
Practice Address - Fax:315-252-7801
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV464363A00000X
NY001190-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002402042Medicaid