Provider Demographics
NPI:1033426556
Name:LEISER, NICHOLAS JOSEPH (PA-C)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JOSEPH
Last Name:LEISER
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 1:1414 STIRLING CT
Mailing Address - Street 2:
Mailing Address - City:PHOENIXVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19460-4813
Mailing Address - Country:US
Mailing Address - Phone:610-933-5133
Mailing Address - Fax:
Practice Address - Street 1:8835 GERMANTOWN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19118-2718
Practice Address - Country:US
Practice Address - Phone:215-248-8200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-03
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054531363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant