Provider Demographics
NPI:1285700781
Name:LEDERER, MARK RICHARD (PA)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:RICHARD
Last Name:LEDERER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:309 KINGSLY LN
Mailing Address - Street 2:
Mailing Address - City:AMERICAN CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:94503-4111
Mailing Address - Country:US
Mailing Address - Phone:707-980-4227
Mailing Address - Fax:866-396-8755
Practice Address - Street 1:309 KINGSLY LN
Practice Address - Street 2:
Practice Address - City:AMERICAN CANYON
Practice Address - State:CA
Practice Address - Zip Code:94503-4111
Practice Address - Country:US
Practice Address - Phone:707-980-4227
Practice Address - Fax:866-396-8755
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA12772363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA289232455720Medicare ID - Type UnspecifiedPHYSICIAN ASSISTANT