Provider Demographics
NPI:1376027540
Name:LEACH, LIZETTE (PA-C)
Entity Type:Individual
Prefix:
First Name:LIZETTE
Middle Name:
Last Name:LEACH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 N GRAND AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:NOGALES
Mailing Address - State:AZ
Mailing Address - Zip Code:85621-1061
Mailing Address - Country:US
Mailing Address - Phone:520-281-1550
Mailing Address - Fax:520-281-1112
Practice Address - Street 1:1852 N MASTICK WAY
Practice Address - Street 2:
Practice Address - City:NOGALES
Practice Address - State:AZ
Practice Address - Zip Code:85621-1063
Practice Address - Country:US
Practice Address - Phone:520-281-1550
Practice Address - Fax:520-281-1112
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-24
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7306363A00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ482965Medicaid
AZ7306OtherARIZONA REGULATORY BOARD OF PHYSICIAN ASSISTANTS