Provider Demographics
NPI:1235606138
Name:LEATHERWOOD, CODY
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:LEATHERWOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 774
Mailing Address - Street 2:
Mailing Address - City:BUCHANAN
Mailing Address - State:GA
Mailing Address - Zip Code:30113-0774
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:302 CATAMARAN RD
Practice Address - Street 2:
Practice Address - City:SWANSBORO
Practice Address - State:NC
Practice Address - Zip Code:28584-2505
Practice Address - Country:US
Practice Address - Phone:770-853-6522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8665363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant