Provider Demographics
NPI:1578504379
Name:LEISURE, MARKETA KYNCL (MD)
Entity Type:Individual
Prefix:
First Name:MARKETA
Middle Name:KYNCL
Last Name:LEISURE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-6708
Mailing Address - Country:US
Mailing Address - Phone:916-924-8754
Mailing Address - Fax:916-924-1739
Practice Address - Street 1:755 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-6708
Practice Address - Country:US
Practice Address - Phone:916-924-8754
Practice Address - Fax:916-924-1739
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101044383208000000X
CA220519208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA3010236959Medicaid
VAF81320Medicare UPIN