Provider Demographics
NPI:1659017499
Name:LEADING EDGE HEALTHCARE, PLLC
Entity Type:Organization
Organization Name:LEADING EDGE HEALTHCARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRKEENG
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:928-925-2871
Mailing Address - Street 1:2182 MARK AVE
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1029
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:724 N MONTEZUMA ST STE A
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-2066
Practice Address - Country:US
Practice Address - Phone:928-925-2871
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-05
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty