Provider Demographics
NPI:1669640827
Name:CLARKE, LEAH ANN (PA)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:ANN
Last Name:CLARKE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 LAS TABLAS RD B
Mailing Address - Street 2:
Mailing Address - City:TEMPLETON
Mailing Address - State:CA
Mailing Address - Zip Code:93465-9711
Mailing Address - Country:US
Mailing Address - Phone:805-434-5563
Mailing Address - Fax:805-434-9516
Practice Address - Street 1:135 CARMEN LN
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93458-7729
Practice Address - Country:US
Practice Address - Phone:805-928-7361
Practice Address - Fax:805-928-4752
Is Sole Proprietor?:No
Enumeration Date:2008-02-11
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20134363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA20134OtherSTATE MEDICAL BOARD PHYSICIAN ASSISTANT LICENSE
CABS395XMedicare PIN
CABS395YMedicare PIN