Provider Demographics
NPI:1619967601
Name:LEAS, EDWARD (PA)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:LEAS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 SUNSET BLVD
Mailing Address - Street 2:P O BOX 758
Mailing Address - City:CONRAD
Mailing Address - State:MT
Mailing Address - Zip Code:59425-0758
Mailing Address - Country:US
Mailing Address - Phone:406-271-3211
Mailing Address - Fax:406-271-3912
Practice Address - Street 1:805 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:CONRAD
Practice Address - State:MT
Practice Address - Zip Code:59425-1717
Practice Address - Country:US
Practice Address - Phone:406-271-3211
Practice Address - Fax:406-271-3912
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT388363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant