Provider Demographics
NPI:1609240688
Name:MAR, LEIGHTON WELDON
Entity Type:Individual
Prefix:
First Name:LEIGHTON
Middle Name:WELDON
Last Name:MAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11346 28TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98125-6727
Mailing Address - Country:US
Mailing Address - Phone:916-761-7379
Mailing Address - Fax:
Practice Address - Street 1:11346 28TH AVE NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98125-6727
Practice Address - Country:US
Practice Address - Phone:916-761-7379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-13
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAIR60502319390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program