Provider Demographics
NPI:1801225800
Name:LEACH, TIFFANY L (PA-C)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:L
Last Name:LEACH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:PRESQUE ISLE
Mailing Address - State:ME
Mailing Address - Zip Code:04769-2240
Mailing Address - Country:US
Mailing Address - Phone:120-776-8456
Mailing Address - Fax:
Practice Address - Street 1:19 NORTH ST
Practice Address - Street 2:
Practice Address - City:PRESQUE ISLE
Practice Address - State:ME
Practice Address - Zip Code:04769-2240
Practice Address - Country:US
Practice Address - Phone:207-768-4568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-11
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA1437363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1801225800Medicaid