Provider Demographics
NPI:1740282441
Name:LEACH, JAMES MICHAEL (PA-C)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:MICHAEL
Last Name:LEACH
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 1:1515 NW 18TH AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2516
Mailing Address - Country:US
Mailing Address - Phone:503-542-4849
Mailing Address - Fax:
Practice Address - Street 1:1515 NW 18TH AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2516
Practice Address - Country:US
Practice Address - Phone:503-542-4849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00613363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORS83767Medicare UPIN
OR106492Medicare PIN