Provider Demographics
NPI:1326034539
Name:LEISTER, CARRIE A (PA-C)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:A
Last Name:LEISTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:A
Other - Last Name:LEISTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:4465 DARROW RD
Mailing Address - Street 2:STE 100
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224
Mailing Address - Country:US
Mailing Address - Phone:330-688-9918
Mailing Address - Fax:330-688-6338
Practice Address - Street 1:4465 DARROW RD
Practice Address - Street 2:STE 100
Practice Address - City:STOW
Practice Address - State:OH
Practice Address - Zip Code:44224
Practice Address - Country:US
Practice Address - Phone:330-688-9918
Practice Address - Fax:330-688-6338
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50000944363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0428273Medicaid
OH0428273Medicaid
PA34781Medicare PIN