Provider Demographics
NPI:1134593841
Name:LEACH, LYN (PAC)
Entity type:Individual
Prefix:MR
First Name:LYN
Middle Name:
Last Name:LEACH
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 FERRIS AVE
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-2599
Mailing Address - Country:US
Mailing Address - Phone:972-351-9984
Mailing Address - Fax:972-351-9984
Practice Address - Street 1:1014 FERRIS AVE
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-2599
Practice Address - Country:US
Practice Address - Phone:972-351-9984
Practice Address - Fax:972-351-9984
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-18
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA10239363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical