Provider Demographics
NPI:1285353441
Name:LEEN, MATTHEW GERARD (PA-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:GERARD
Last Name:LEEN
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 1:263 PARKSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:MILLER PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11764-3524
Mailing Address - Country:US
Mailing Address - Phone:631-603-2073
Mailing Address - Fax:
Practice Address - Street 1:390 PIERCE ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5532
Practice Address - Country:US
Practice Address - Phone:570-288-3535
Practice Address - Fax:570-288-0804
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-23
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA063842363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty