Basic Information
| Provider Information | |||||||||
| NPI: | 1417068248 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DELEONARDO | ||||||||
| FirstName: | JACK | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2699 S 167TH DR | ||||||||
| Address2: | |||||||||
| City: | GOODYEAR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853387317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4069272221 | ||||||||
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| Practice Location | |||||||||
| Address1: | 650 E INDIAN SCHOOL RD | ||||||||
| Address2: | DEPT VETERANS AFFAIRS | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022775551 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 11/02/2016 | ||||||||
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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 | 363A00000X | 196 | MT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0433296 | 01 | MT | MDCD PIN | OTHER | 092303 | 01 | MT | BCBS PIN | OTHER | 12355900 | 01 | WY | MDCD PIN | OTHER |