Provider Demographics
NPI:1407947286
Name:BAZAN, LEANDRA BIBIANA (PA-C, MT)
Entity Type:Individual
Prefix:
First Name:LEANDRA
Middle Name:BIBIANA
Last Name:BAZAN
Suffix:
Gender:F
Credentials:PA-C, MT
Other - Prefix:
Other - First Name:LEANDRA
Other - Middle Name:BIBIANA
Other - Last Name:NOSSA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1900 16TH ST
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-5114
Mailing Address - Country:US
Mailing Address - Phone:970-350-2426
Mailing Address - Fax:970-350-2478
Practice Address - Street 1:1900 16TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631
Practice Address - Country:US
Practice Address - Phone:970-350-2426
Practice Address - Fax:970-350-2478
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103879363A00000X
COPA0005128363A00000X
FLTN35171246ZA2600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No246ZA2600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherArt, Medical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1407947286Medicaid