Provider Demographics
NPI:1962487900
Name:LEAHY, MARIANNE B (PA-C)
Entity Type:Individual
Prefix:
First Name:MARIANNE
Middle Name:B
Last Name:LEAHY
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Gender:F
Credentials:PA-C
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Mailing Address - Street 1:8890 N UNION BLVD
Mailing Address - Street 2:SUITE 171
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-7799
Mailing Address - Country:US
Mailing Address - Phone:719-364-5633
Mailing Address - Fax:719-364-5639
Practice Address - Street 1:5818 N NEVADA AVENUE
Practice Address - Street 2:SUITE 110
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7799
Practice Address - Country:US
Practice Address - Phone:719-365-1950
Practice Address - Fax:719-364-5639
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2020-12-30
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Provider Licenses
StateLicense IDTaxonomies
CO960363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO53379594Medicaid
S95919Medicare UPIN
CO53379594Medicaid