Provider Demographics
NPI:1417967217
Name:SEBALD, LEANDRA K (PA)
Entity Type:Individual
Prefix:
First Name:LEANDRA
Middle Name:K
Last Name:SEBALD
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 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9606
Mailing Address - Country:US
Mailing Address - Phone:616-252-3243
Mailing Address - Fax:616-363-7290
Practice Address - Street 1:5900 BYRON CENTER AVE SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519
Practice Address - Country:US
Practice Address - Phone:616-252-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002968363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
N78710002Medicare ID - Type Unspecified