Provider Demographics
NPI:1114944899
Name:LEIBHAM, PAULA (NP)
Entity Type:Individual
Prefix:MS
First Name:PAULA
Middle Name:
Last Name:LEIBHAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5525 GROSSMONT CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3009
Mailing Address - Country:US
Mailing Address - Phone:619-644-6569
Mailing Address - Fax:619-644-6526
Practice Address - Street 1:5525 GROSSMONT CENTER DR STE 200
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3009
Practice Address - Country:US
Practice Address - Phone:619-644-6569
Practice Address - Fax:619-644-6526
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP9939207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS54872Medicare UPIN
CARN518534Medicare ID - Type Unspecified