Provider Demographics
NPI:1952568420
Name:LEON, ROBERT WADE (NP)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:WADE
Last Name:LEON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 W 11TH ST
Mailing Address - Street 2:1C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-8607
Mailing Address - Country:US
Mailing Address - Phone:646-645-9233
Mailing Address - Fax:
Practice Address - Street 1:203 W 12TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-7762
Practice Address - Country:US
Practice Address - Phone:646-645-9233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY301242363LA2200X
NY400786363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ16508Medicare UPIN