Provider Demographics
NPI:1265512966
Name:LEDDY, MICHAEL T (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:LEDDY
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 1:200 S HERLONG AVE STE H
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-1182
Mailing Address - Country:US
Mailing Address - Phone:803-366-6135
Mailing Address - Fax:803-366-3439
Practice Address - Street 1:200 S HERLONG AVE STE H
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1182
Practice Address - Country:US
Practice Address - Phone:803-366-6135
Practice Address - Fax:803-366-3439
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC954363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant