Provider Demographics
NPI:1871110171
Name:LEON, CARLOS ALBERTO
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:ALBERTO
Last Name:LEON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4775 N CONGRESS AVE
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33426-7941
Mailing Address - Country:US
Mailing Address - Phone:561-328-8631
Mailing Address - Fax:561-328-8632
Practice Address - Street 1:4775 N CONGRESS AVE
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-7941
Practice Address - Country:US
Practice Address - Phone:561-328-8631
Practice Address - Fax:561-328-8632
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-02
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11007687363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109153400Medicaid