Provider Demographics
NPI:1174630180
Name:COTA, LEANNE R (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LEANNE
Middle Name:R
Last Name:COTA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LEANNE
Other - Middle Name:R
Other - Last Name:BREIHAHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 4
Mailing Address - Street 2:
Mailing Address - City:PLEVNA
Mailing Address - State:MT
Mailing Address - Zip Code:59344-0004
Mailing Address - Country:US
Mailing Address - Phone:406-778-7750
Mailing Address - Fax:406-772-5849
Practice Address - Street 1:150 FRONT ST
Practice Address - Street 2:
Practice Address - City:TANANA
Practice Address - State:AK
Practice Address - Zip Code:99777
Practice Address - Country:US
Practice Address - Phone:907-366-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT36234363A00000X
TNPA0000001325363A00000X
AK170876363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK170876OtherALASKA MEDICAL LICENSE
MTMEDPACLIC36234OtherMONTANA MEDICAL LICENSE
TNPA0000001325OtherMEDICAL LICENSE NUMBER
TN4131704OtherBLUE CROSS BLUE SHIELD
TNPA0000001325OtherMEDICAL LICENSE NUMBER
TNMB1363516OtherDEA
TN3377550Medicare ID - Type UnspecifiedEMPLOYER GROUP MEDICARE #
TN3664367Medicare ID - Type UnspecifiedINDIVIDUAL MEDICAL