Provider Demographics
NPI:1649863325
Name:LEICHT, ZANE D (PA-C)
Entity type:Individual
Prefix:
First Name:ZANE
Middle Name:D
Last Name:LEICHT
Suffix:
Gender:M
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 1:2315 MYRTLE ST STE L90
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16502-4607
Mailing Address - Country:US
Mailing Address - Phone:814-452-7575
Mailing Address - Fax:
Practice Address - Street 1:2315 MYRTLE ST STE L90
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16502-4607
Practice Address - Country:US
Practice Address - Phone:814-452-7575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-15
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA062088363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
15126273OtherCAQH