Provider Demographics
NPI:1801809363
Name:LEAF, BETH ANN M (PA)
Entity type:Individual
Prefix:
First Name:BETH ANN
Middle Name:M
Last Name:LEAF
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1834 FIRCREST CT
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33543-8168
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1942 HIGHLAND OAKS BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33559-7410
Practice Address - Country:US
Practice Address - Phone:813-948-3838
Practice Address - Fax:813-949-0629
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103104363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292838800Medicaid
FLP00625639OtherRR MEDICARE
FLAE197ZMedicare PIN