Provider Demographics
NPI:1265653596
Name:LEAVITT, EDWIN LOCKWOOD (PA-C)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:LOCKWOOD
Last Name:LEAVITT
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 1:2043 RIVER DOWNS CT
Mailing Address - Street 2:
Mailing Address - City:FOREST HILL
Mailing Address - State:MD
Mailing Address - Zip Code:21050-3142
Mailing Address - Country:US
Mailing Address - Phone:443-845-6295
Mailing Address - Fax:301-677-7149
Practice Address - Street 1:2257 HUBER ROAD
Practice Address - Street 2:
Practice Address - City:FORT MEADE
Practice Address - State:MD
Practice Address - Zip Code:20755-5378
Practice Address - Country:US
Practice Address - Phone:443-845-6295
Practice Address - Fax:301-677-7149
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001832363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant