Basic Information
| Provider Information | |||||||||
| NPI: | 1962487900 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEAHY | ||||||||
| FirstName: | MARIANNE | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8890 N UNION BLVD | ||||||||
| Address2: | SUITE 171 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809207799 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193645633 | ||||||||
| FaxNumber: | 7193645639 | ||||||||
| Practice Location | |||||||||
| Address1: | 5818 N NEVADA AVENUE | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809207799 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193651950 | ||||||||
| FaxNumber: | 7193645639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2005 | ||||||||
| LastUpdateDate: | 12/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 960 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 53379594 | 05 | CO | MEDICAID |