Provider Demographics
NPI:1275959942
Name:PATRICK, LEAH IVY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LEAH
Middle Name:IVY
Last Name:PATRICK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:LEAH
Other - Middle Name:IVY
Other - Last Name:RICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4715 WHITESBURG DR SE
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35802-1649
Mailing Address - Country:US
Mailing Address - Phone:256-881-5151
Mailing Address - Fax:256-880-3939
Practice Address - Street 1:4715 WHITESBURG DR SE
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35802-1649
Practice Address - Country:US
Practice Address - Phone:256-881-5151
Practice Address - Fax:256-880-3939
Is Sole Proprietor?:No
Enumeration Date:2014-03-05
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA.2107363A00000X
MO2014005588363A00000X
SCTL2808363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0037PAMedicaid
ALPA.2107OtherMEDICAL LICENSE