Provider Demographics
NPI:1851559967
Name:LELAND, BRIAN KEITH (PA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
Last Name:LELAND
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 1:120 STONEBRIDGE PKWY
Mailing Address - Street 2:320
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-3767
Mailing Address - Country:US
Mailing Address - Phone:770-874-7631
Mailing Address - Fax:
Practice Address - Street 1:61 WHITCHER ST NE
Practice Address - Street 2:SUITE 2100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1176
Practice Address - Country:US
Practice Address - Phone:770-423-0595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-26
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9104493363AS0400X
GA005349363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical