Provider Demographics
NPI:1790754257
Name:LEITNAKER, MOLLY JO (PA)
Entity Type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:JO
Last Name:LEITNAKER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:MOLLY
Other - Middle Name:JO
Other - Last Name:HAMILTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 434
Mailing Address - Street 2:
Mailing Address - City:KEMPNER
Mailing Address - State:TX
Mailing Address - Zip Code:76539-0434
Mailing Address - Country:US
Mailing Address - Phone:303-815-3993
Mailing Address - Fax:
Practice Address - Street 1:458 TOWN SQ
Practice Address - Street 2:COPPERAS COVE MEDICAL HOME
Practice Address - City:COPPERAS COVE
Practice Address - State:TX
Practice Address - Zip Code:76522-2826
Practice Address - Country:US
Practice Address - Phone:254-553-5801
Practice Address - Fax:254-547-3297
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO422363A00000X
TX06996363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01322502Medicaid
CO01322502Medicaid