Provider Demographics
NPI:1740650548
Name:LEAVITT, BRENT
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:LEAVITT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4928 PLEASANT VIEW DR
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-1640
Mailing Address - Country:US
Mailing Address - Phone:208-760-9416
Mailing Address - Fax:
Practice Address - Street 1:4928 PLEASANT VIEW DR
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-1640
Practice Address - Country:US
Practice Address - Phone:208-760-9416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1299363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant