Provider Demographics
NPI:1518950369
Name:BLACK, LEAH AUTRY (PA C)
Entity Type:Individual
Prefix:MRS
First Name:LEAH
Middle Name:AUTRY
Last Name:BLACK
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
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Mailing Address - Street 1:1327 ROBESON ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28305-5531
Mailing Address - Country:US
Mailing Address - Phone:910-486-5437
Mailing Address - Fax:910-486-0011
Practice Address - Street 1:1327 ROBESON ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-5531
Practice Address - Country:US
Practice Address - Phone:910-486-5437
Practice Address - Fax:910-486-5437
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2022-07-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC102900363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant