Basic Information
| Provider Information | |||||||||
| NPI: | 1184645509 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EWING | ||||||||
| FirstName: | LEONA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 300 | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170420300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172707780 | ||||||||
| FaxNumber: | 7172749746 | ||||||||
| Practice Location | |||||||||
| Address1: | 850 TUCK ST | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170427477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172735803 | ||||||||
| FaxNumber: | 7172728422 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 11/06/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | OS003439L | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 143362 | 01 | PA | HIGHMARK | OTHER | 0006286030002 | 05 | PA | MEDICAID |