Provider Demographics
NPI:1326334970
Name:PAGE, LEAH CO (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MISS
First Name:LEAH
Middle Name:CO
Last Name:PAGE
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 MDOS/SGOF
Mailing Address - Street 2:UNIT 3215
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09094-5300
Mailing Address - Country:US
Mailing Address - Phone:314-479-1383
Mailing Address - Fax:
Practice Address - Street 1:86 MDOS/SGOF
Practice Address - Street 2:UNIT 3215
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09094-5300
Practice Address - Country:US
Practice Address - Phone:314-479-1383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-22
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA713530163WM0705X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical