Provider Demographics
NPI:1295879062
Name:BOYKIN WILLSON, LEISA A (PA)
Entity type:Individual
Prefix:MS
First Name:LEISA
Middle Name:A
Last Name:BOYKIN WILLSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2695 ROCKY MOUNTAIN AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9071
Mailing Address - Country:US
Mailing Address - Phone:970-624-4451
Mailing Address - Fax:970-490-4199
Practice Address - Street 1:311 STEELE ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206-4479
Practice Address - Country:US
Practice Address - Phone:303-372-4000
Practice Address - Fax:303-372-4001
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO1539363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO16377044Medicaid
004704OtherKAISER-COMMERCIAL NUMBER
004704OtherKAISER-COMMERCIAL NUMBER
CO16377044Medicaid
COCK11330Medicare PIN