Basic Information
| Provider Information | |||||||||
| NPI: | 1285353441 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEEN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | GERARD | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 263 PARKSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | MILLER PLACE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117643524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316032073 | ||||||||
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| Practice Location | |||||||||
| Address1: | 390 PIERCE ST | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187045532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702883535 | ||||||||
| FaxNumber: | 5702880804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2022 | ||||||||
| LastUpdateDate: | 11/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MA063842 | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.