Provider Demographics
NPI:1669006508
Name:QUACH, LEAH NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:LEAH NICOLE
Middle Name:
Last Name:QUACH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LEAH NICOLE
Other - Middle Name:
Other - Last Name:DE JESUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:9106 68TH AVE
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-5724
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1027 46TH AVE
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-5245
Practice Address - Country:US
Practice Address - Phone:212-385-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-01
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025158363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant