Provider Demographics
NPI:1407835333
Name:EMMERTON, LEAWOOD P (PA C)
Entity Type:Individual
Prefix:MR
First Name:LEAWOOD
Middle Name:P
Last Name:EMMERTON
Suffix:
Gender:M
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 1:630 PLANTATION ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605
Mailing Address - Country:US
Mailing Address - Phone:508-368-3130
Mailing Address - Fax:
Practice Address - Street 1:123 SUMMER ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1216
Practice Address - Country:US
Practice Address - Phone:508-368-3130
Practice Address - Fax:508-368-3167
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA60363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAP0271Medicare ID - Type Unspecified
S26486Medicare UPIN
AP1244OtherBLUE SHIELD INDEMNITY
MAAP0271Medicare ID - Type Unspecified
AP0271OtherMEDICARE B
S26486Medicare UPIN