Provider Demographics
NPI:1528108339
Name:LEONARDI, TETY (PA-C, LD)
Entity type:Individual
Prefix:
First Name:TETY
Middle Name:
Last Name:LEONARDI
Suffix:
Gender:F
Credentials:PA-C, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 HOLLOW WAY
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75041-2186
Mailing Address - Country:US
Mailing Address - Phone:254-421-2502
Mailing Address - Fax:
Practice Address - Street 1:2110 HOLLOW WAY
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75041-2186
Practice Address - Country:US
Practice Address - Phone:254-421-2502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT07391133V00000X
TXPA07936363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX270086YKQLMedicare PIN