Provider Demographics
NPI:1336751494
Name:LEIBA, KALUM (CAA)
Entity Type:Individual
Prefix:
First Name:KALUM
Middle Name:
Last Name:LEIBA
Suffix:
Gender:M
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4708 ARDMORE LN
Mailing Address - Street 2:
Mailing Address - City:HOSCHTON
Mailing Address - State:GA
Mailing Address - Zip Code:30548-6227
Mailing Address - Country:US
Mailing Address - Phone:404-563-2645
Mailing Address - Fax:
Practice Address - Street 1:450 NORTHSIDE CHEROKEE BLVD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-8015
Practice Address - Country:US
Practice Address - Phone:770-224-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant