Provider Demographics
NPI:1437798295
Name:LEOS, LETICHA ANTONIONETTE (PA)
Entity Type:Individual
Prefix:MS
First Name:LETICHA
Middle Name:ANTONIONETTE
Last Name:LEOS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:7195 ADVANCED WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-3691
Mailing Address - Country:US
Mailing Address - Phone:702-740-5327
Mailing Address - Fax:702-597-2067
Practice Address - Street 1:7195 ADVANCED WAY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113-3691
Practice Address - Country:US
Practice Address - Phone:702-740-5327
Practice Address - Fax:702-597-2067
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-26
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA0456363A00000X
TXPA16874363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant