Provider Demographics
NPI:1376026047
Name:HOLDER, LEANN (PA)
Entity Type:Individual
Prefix:
First Name:LEANN
Middle Name:
Last Name:HOLDER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LEANN
Other - Middle Name:
Other - Last Name:PATTERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 138
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:KS
Mailing Address - Zip Code:67118-0138
Mailing Address - Country:US
Mailing Address - Phone:316-285-3650
Mailing Address - Fax:
Practice Address - Street 1:13213 W 21ST CT
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67235-9625
Practice Address - Country:US
Practice Address - Phone:316-612-1833
Practice Address - Fax:316-612-2420
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1502650363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO220059989Medicaid