Provider Demographics
NPI:1629540109
Name:LEIB, EMILY (PA)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:LEIB
Suffix:
Gender:F
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 1:1507 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GATESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76528-1024
Mailing Address - Country:US
Mailing Address - Phone:254-865-2166
Mailing Address - Fax:254-248-6303
Practice Address - Street 1:404 AVENUE E
Practice Address - Street 2:
Practice Address - City:MOODY
Practice Address - State:TX
Practice Address - Zip Code:76557-3579
Practice Address - Country:US
Practice Address - Phone:254-853-9603
Practice Address - Fax:254-248-0626
Is Sole Proprietor?:No
Enumeration Date:2018-12-21
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA12459363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant