Basic Information
| Provider Information | |||||||||
| NPI: | 1235462813 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | STOR | ||||||||
| FirstName: | LEON | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11750 W 2ND PL | ||||||||
| Address2: | SUITE 255 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802281575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7203218040 | ||||||||
| FaxNumber: | 7203218041 | ||||||||
| Practice Location | |||||||||
| Address1: | 11750 W 2ND PL | ||||||||
| Address2: | SUITE 255 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802281575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7203218040 | ||||||||
| FaxNumber: | 7203218041 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2009 | ||||||||
| LastUpdateDate: | 04/10/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | PA-2907 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 91104530 | 05 | CO | MEDICAID |