Provider Demographics
NPI:1265816722
Name:LEAVITT, HALLIE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:HALLIE
Middle Name:
Last Name:LEAVITT
Suffix:
Gender:F
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 1:622 W 168TH ST
Mailing Address - Street 2:VC2 SUITE #260
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3720
Mailing Address - Country:US
Mailing Address - Phone:847-302-5297
Mailing Address - Fax:
Practice Address - Street 1:622 W 168TH ST
Practice Address - Street 2:VC2 SUITE #260
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3720
Practice Address - Country:US
Practice Address - Phone:847-302-5297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-15
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018721363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant