Provider Demographics
NPI:1174863724
Name:LEYVA, SUSANA M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SUSANA
Middle Name:M
Last Name:LEYVA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SUSANA
Other - Middle Name:M
Other - Last Name:GRAJEDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3700 N 24TH ST STE 210
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-6536
Mailing Address - Country:US
Mailing Address - Phone:602-840-0681
Mailing Address - Fax:602-957-1570
Practice Address - Street 1:3700 N 24TH ST STE 210
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-6536
Practice Address - Country:US
Practice Address - Phone:602-840-0681
Practice Address - Fax:602-957-1570
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5352363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant