Leon Koenck, PA C
Individual provider Active NPI Physician Assistant · Gualala, CA
NPI 1164555769 · NPPES record last updated Feb 2, 2016
Key facts
- NPI
- 1164555769
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Physician Assistant 363A00000X
- License
- PA19714 (CA)
- Practice address
- 46900 Ocean Dr
Ste 1100
Gualala, CA 95445-8353 - Phone
- (707) 884-4005
- Fax
- (707) 884-4625
- NPI assigned
- Mar 13, 2007
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 6
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in CA
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20150528001782 | CA | Practitioner - Physician Assistant | 8820088800 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 270 | AK | MD | Marriage & Family Therapist |
| PA19714 | CA | MD | Physician Assistant |
| PA 10003212 | WA | MD | Physician Assistant |
| PA10003212 | WA | MD | Medical Physician Assistant |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Redwood Coast Medical Services, Inc. | Current |
Accepting new patients | |
| Camai Community Health Center, Inc. | Past |
Accepting new patients | |
| Bristol Bay Borough | Past | Accepting new patients | |
| Alaska Imaging Associates, LLC | Past | Accepting new patients | |
| Winnebago Indian Health Service | Past |
Accepting new patients |
Interoperability endpoints
- leon.koenck.p1@direct.rcms-healthcare.nextgenshare.com
- https://fhir.nextgen.com/nge/prod/fhir-api-r4/fhir/r4/
- https://api.platform.athenahealth.com/20726/brand/1/csg/1/fhir/r4
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | 270 | AK | |
| Physician Assistant | 363A00000X | PA19714 | CA | Yes |
| Physician Assistant | 363A00000X | PA 10003212 | WA | |
| Medical Physician Assistant | 363AM0700X | PA19714 | CA | |
| Medical Physician Assistant | 363AM0700X | PA10003212 | WA |
Addresses
Primary practice location
46900 Ocean Dr
Ste 1100
Gualala, CA 95445-8353
Mailing address
200 West 34TH Avenue
#539
Anchorage, AK 99503
Phone (888) 300-0137
Other providers in Gualala, CA
- Carolyn Hand
- Douglas Scott Herting
- Stephanie Hsieh
- Mark Kal
- Renee Kaucnik
- Lisa Heying Kritz
- Shaye Larie
- Lisa Kritz Physical Therapy Inc.
- Lucinda Weaver Physical Therapy
- Jessica B Maness
All providers in Gualala, CA · Physician Assistant in California
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Feb 2, 2016. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.