Individual
MRS. CORALIA ILINCA LEYDERMAN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
1601 WENTZVILLE PKWY STE 117, WENTZVILLE, MO 63385-3814
(636) 332-8455
Mailing address
3635 VISTA AVE, SAINT LOUIS, MO 63110-2539
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
2014025990
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1119413
NCCPA
—
01
—
2014025990
MISSOURI STATE PA LICENSE
MO
Enumeration date
12/11/2014
Last updated
11/12/2020
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