Provider Demographics
NPI:1295132504
Name:BRODIE, LEAH (PA-C)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:BRODIE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 KEARSING PKWY
Mailing Address - Street 2:
Mailing Address - City:MONSEY
Mailing Address - State:NY
Mailing Address - Zip Code:10952-2243
Mailing Address - Country:US
Mailing Address - Phone:845-893-5584
Mailing Address - Fax:
Practice Address - Street 1:176 KEARSING PKWY
Practice Address - Street 2:
Practice Address - City:MONSEY
Practice Address - State:NY
Practice Address - Zip Code:10952-2243
Practice Address - Country:US
Practice Address - Phone:845-893-5584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-02
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017842-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant