Provider Demographics
NPI:1710291471
Name:DVORKIN, LEAH ILENE (PA-C, ATC, OT-SC)
Entity Type:Individual
Prefix:MS
First Name:LEAH
Middle Name:ILENE
Last Name:DVORKIN
Suffix:
Gender:F
Credentials:PA-C, ATC, OT-SC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 AVENUE PL
Mailing Address - Street 2:#1403
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-4015
Mailing Address - Country:US
Mailing Address - Phone:970-376-8041
Mailing Address - Fax:
Practice Address - Street 1:181 W MEADOW DR
Practice Address - Street 2:
Practice Address - City:VAIL
Practice Address - State:CO
Practice Address - Zip Code:81657-5242
Practice Address - Country:US
Practice Address - Phone:970-476-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-04
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO09-0838246ZS0410X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist