Provider Demographics
NPI:1538381488
Name:LEO, COREY WAYNE (PA-C)
Entity type:Individual
Prefix:MR
First Name:COREY
Middle Name:WAYNE
Last Name:LEO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2607 MCDANIEL AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1407
Mailing Address - Country:US
Mailing Address - Phone:319-321-2575
Mailing Address - Fax:
Practice Address - Street 1:1801 16TH ST
Practice Address - Street 2:BOX 5180
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-5154
Practice Address - Country:US
Practice Address - Phone:970-350-6066
Practice Address - Fax:970-350-6274
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL85002510363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant