Provider Demographics
NPI:1538111307
Name:LEASURE, NICK C (MD)
Entity Type:Individual
Prefix:
First Name:NICK
Middle Name:C
Last Name:LEASURE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 16052
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19612-6052
Mailing Address - Country:US
Mailing Address - Phone:610-374-4404
Mailing Address - Fax:610-374-1396
Practice Address - Street 1:S 6TH AVENUE & SPRUCE ST
Practice Address - Street 2:TRHMC REGIONAL CANCER CENTER N GROUND
Practice Address - City:WEST READING
Practice Address - State:PA
Practice Address - Zip Code:19611
Practice Address - Country:US
Practice Address - Phone:610-374-4404
Practice Address - Fax:610-374-1396
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD032114E207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011250820003Medicaid
20010538OtherAMERIHEALTH MERCY
PA01433301OtherBLUE CROSS
128101OtherUNISON
PA038219OtherHIGHMARK BLUE SHIELD
110039797OtherRAILROAD MEDICARE
20010538OtherAMERIHEALTH MERCY
110039797OtherRAILROAD MEDICARE