Provider Demographics
NPI:1629552435
Name:KOSHY, LEENA CHACKO (PA-C)
Entity Type:Individual
Prefix:
First Name:LEENA
Middle Name:CHACKO
Last Name:KOSHY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 GEORGE W LILES PKWY NW
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-8218
Mailing Address - Country:US
Mailing Address - Phone:048-861-7807
Mailing Address - Fax:
Practice Address - Street 1:12011 OLD TIMBER RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-8750
Practice Address - Country:US
Practice Address - Phone:704-574-7216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-07927363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant