Provider Demographics
NPI:1508074170
Name:LEON, MARIO (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:LEON
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 1:6787 EXETER ST
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-4150
Mailing Address - Country:US
Mailing Address - Phone:347-257-0575
Mailing Address - Fax:
Practice Address - Street 1:800 POLY PL
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-7104
Practice Address - Country:US
Practice Address - Phone:718-836-6630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011824-1363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant