Provider Demographics
NPI:1396755583
Name:LEON, RICARDO
Entity type:Individual
Prefix:
First Name:RICARDO
Middle Name:
Last Name:LEON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 MARYS AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-5849
Mailing Address - Country:US
Mailing Address - Phone:631-232-4000
Mailing Address - Fax:631-851-9225
Practice Address - Street 1:105 MARYS AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-5848
Practice Address - Country:US
Practice Address - Phone:845-338-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008394363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant