Provider Demographics
NPI:1508149634
Name:LEEFLANG, JOHAN NICOLAAS (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHAN
Middle Name:NICOLAAS
Last Name:LEEFLANG
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 1:1490 E FOREMASTER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-4496
Mailing Address - Country:US
Mailing Address - Phone:435-628-1641
Mailing Address - Fax:
Practice Address - Street 1:1490 E FOREMASTER DR STE 200
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-4496
Practice Address - Country:US
Practice Address - Phone:435-628-1641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-26
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6496047-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant