1417979220 NPI number — LEIGH K PRESTON PA-C

Table of content: LEIGH K PRESTON PA-C (NPI 1417979220)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417979220 NPI number — LEIGH K PRESTON PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRESTON
Provider First Name:
LEIGH
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417979220
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
537 STANTON CHRISTIANA RD
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19713-2146
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-398-4679
Provider Business Mailing Address Fax Number:
302-225-2388

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
537 STANTON CHRISTIANA RD
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19713-2146
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-225-2380
Provider Business Practice Location Address Fax Number:
302-225-2388
Provider Enumeration Date:
07/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  C50000618 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208M00000X , with the licence number: C0002871 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 10004210A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 300083791 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 522057354 . This is a "BLUE SHIELD OF DELAWARE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 0000845902 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00229980 . This is a "MEDICARE RAILROAD" identifier . This identifiers is of the category "OTHER".




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