Provider Demographics
NPI:1407058936
Name:MACMARTIN, LEAH C (PA)
Entity Type:Individual
Prefix:MRS
First Name:LEAH
Middle Name:C
Last Name:MACMARTIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 E BIG BEAVER RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1262
Mailing Address - Country:US
Mailing Address - Phone:586-779-3030
Mailing Address - Fax:586-779-6733
Practice Address - Street 1:85 E BIG BEAVER RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-1262
Practice Address - Country:US
Practice Address - Phone:586-779-3030
Practice Address - Fax:586-779-6733
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005043207N00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN135200004Medicare PIN