Basic Information
| Provider Information | |||||||||
| NPI: | 1114986759 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | LEONARD | ||||||||
| MiddleName: | GREGORY | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.A.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2920 HIGHWOODS BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276041556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774984490 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3000 NEW BERN AVE | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276101231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193508000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 01/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 101655 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 101665 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 3016840 | 01 | NC | AETNA | OTHER | 97582 | 01 | NC | MEDCOST | OTHER | 0190E | 01 | NC | BCBS GROUP | OTHER | 1114986759 | 05 | NC | MEDICAID | 231662 | 01 | NC | UHC | OTHER | 890190E | 05 | NC | MEDICAID | 313454 | 01 | NC | WELLPATH | OTHER |