Provider Demographics
NPI:1750331476
Name:LEATHERWOOD, STEPHEN HUNT (PA)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:HUNT
Last Name:LEATHERWOOD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 MARTHA BERRY BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1625
Mailing Address - Country:US
Mailing Address - Phone:706-295-5331
Mailing Address - Fax:
Practice Address - Street 1:550 REDMOND RD NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1416
Practice Address - Country:US
Practice Address - Phone:706-233-8512
Practice Address - Fax:706-233-8513
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005118363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA261031502FMedicaid
GA261031502JMedicaid
GA261031502GMedicaid
GA261031502EMedicaid
GA261031502GMedicaid