Provider Demographics
NPI:1265548820
Name:LEAK, JOHN (PA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:LEAK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:612 N 13TH ST STE H
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:NM
Mailing Address - Zip Code:88210-1167
Mailing Address - Country:US
Mailing Address - Phone:575-746-8880
Mailing Address - Fax:575-746-2416
Practice Address - Street 1:2420 W PIERCE ST
Practice Address - Street 2:STE 205
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-3543
Practice Address - Country:US
Practice Address - Phone:575-887-0530
Practice Address - Fax:575-885-6309
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2012-07-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM97-PA26363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM37376781Medicaid
NM00NM00RE62OtherBCBS
NM37376781Medicaid