Provider Demographics
NPI:1821096850
Name:WAY, LEA E (CFNP)
Entity Type:Individual
Prefix:MRS
First Name:LEA
Middle Name:E
Last Name:WAY
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:MRS
Other - First Name:LEA
Other - Middle Name:E
Other - Last Name:WAY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CFNP
Mailing Address - Street 1:PO BOX 728
Mailing Address - Street 2:
Mailing Address - City:YARNELL
Mailing Address - State:AZ
Mailing Address - Zip Code:85362-0728
Mailing Address - Country:US
Mailing Address - Phone:928-427-3411
Mailing Address - Fax:928-427-6541
Practice Address - Street 1:22869 US HWY 89
Practice Address - Street 2:
Practice Address - City:YARNELL
Practice Address - State:AZ
Practice Address - Zip Code:85362
Practice Address - Country:US
Practice Address - Phone:928-427-3411
Practice Address - Fax:928-427-6541
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ154207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ141317001OtherMERCYCALL
AZ860815386001OtherTRICARE
AZ860815386001OtherTRICARE
AZ141317001OtherMERCYCALL