Provider Demographics
NPI:1346929619
Name:LEACH, BRONC SKYLER
Entity Type:Individual
Prefix:
First Name:BRONC
Middle Name:SKYLER
Last Name:LEACH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 FILLIPPELLI DR
Mailing Address - Street 2:
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-3930
Mailing Address - Country:US
Mailing Address - Phone:417-389-2376
Mailing Address - Fax:
Practice Address - Street 1:915 FILLIPPELLI DR
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-3930
Practice Address - Country:US
Practice Address - Phone:417-389-2376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-14
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA775283163W00000X
CA95025970363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse