Provider Demographics
NPI:1023585254
Name:LEBLANC, WAYNE ALLEN (PA-C)
Entity type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:ALLEN
Last Name:LEBLANC
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4716 BEACH RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094
Mailing Address - Country:US
Mailing Address - Phone:716-622-9568
Mailing Address - Fax:
Practice Address - Street 1:6334 ROBINSON RD
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-7977
Practice Address - Country:US
Practice Address - Phone:716-622-9568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025063363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty