Provider Demographics
NPI:1033327705
Name:LEAVITT, LARRY (PA)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:
Last Name:LEAVITT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:369 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-6803
Mailing Address - Country:US
Mailing Address - Phone:518-772-7710
Mailing Address - Fax:518-772-7710
Practice Address - Street 1:369 SOUTH ST
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-6803
Practice Address - Country:US
Practice Address - Phone:518-772-7710
Practice Address - Fax:518-772-7710
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3089363A00000X
NH0643363A00000X
NH003089363A00000X
MA2589363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30336040Medicaid
0002035Medicare PIN