Provider Demographics
NPI:1114560851
Name:LEONHARDT, BRIAN PAUL (PA-C)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:PAUL
Last Name:LEONHARDT
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 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:856-355-0340
Mailing Address - Fax:856-355-0330
Practice Address - Street 1:1113 HOSPITAL DRIVE PROFESSIONAL BUILDING EAST
Practice Address - Street 2:SUITE 100
Practice Address - City:WILLINGBORO
Practice Address - State:NJ
Practice Address - Zip Code:08046
Practice Address - Country:US
Practice Address - Phone:609-835-5821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-25
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00551300363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0718157Medicaid