Provider Demographics
NPI:1396302121
Name:LEONARD, MARK ANTHONY (CAA)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANTHONY
Last Name:LEONARD
Suffix:
Gender:M
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14612 CHATSWORTH MANOR CIR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-3304
Mailing Address - Country:US
Mailing Address - Phone:813-389-3884
Mailing Address - Fax:
Practice Address - Street 1:9330 STATE ROAD 54
Practice Address - Street 2:MEDICAL CENTER OF TRINITY
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655
Practice Address - Country:US
Practice Address - Phone:727-834-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAA509367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant