Provider Demographics
NPI:1932164605
Name:COLLARD, LELAND I (PA)
Entity Type:Individual
Prefix:
First Name:LELAND
Middle Name:I
Last Name:COLLARD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39000 BOB HOPE DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-3221
Mailing Address - Country:US
Mailing Address - Phone:760-773-1451
Mailing Address - Fax:760-773-1239
Practice Address - Street 1:39000 BOB HOPE DR
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3221
Practice Address - Country:US
Practice Address - Phone:760-568-4330
Practice Address - Fax:760-568-6470
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003570363AS0400X
IDPA602363AS0400X
CAPA61588363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807423000Medicaid