Provider Demographics
NPI:1275578312
Name:LEAF, PHILLIP GREGORY (NP)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:GREGORY
Last Name:LEAF
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 E H ST
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-4760
Mailing Address - Country:US
Mailing Address - Phone:906-774-3300
Mailing Address - Fax:906-779-3180
Practice Address - Street 1:325 E H ST
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-4760
Practice Address - Country:US
Practice Address - Phone:906-774-3300
Practice Address - Fax:906-779-3180
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704206304363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health