Provider Demographics
NPI:1407832116
Name:BUCK, LEANNE IRENE (PA C)
Entity Type:Individual
Prefix:
First Name:LEANNE
Middle Name:IRENE
Last Name:BUCK
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 1:20 W NORTH ST
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-3117
Mailing Address - Country:US
Mailing Address - Phone:970-565-7011
Mailing Address - Fax:970-565-3277
Practice Address - Street 1:20 W NORTH ST
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-3117
Practice Address - Country:US
Practice Address - Phone:970-565-7011
Practice Address - Fax:970-565-3277
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAK605363A00000X
COPA.0004538363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM16480821Medicaid
CO76830080Medicaid
AKCL7624Medicaid