1295879062 NPI number — MS. LEISA A BOYKIN WILLSON PA

Table of content: MS. LEISA A BOYKIN WILLSON PA (NPI 1295879062)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295879062 NPI number — MS. LEISA A BOYKIN WILLSON PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOYKIN WILLSON
Provider First Name:
LEISA
Provider Middle Name:
A
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PA
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:
1295879062
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2695 ROCKY MOUNTAIN AVE STE 150
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOVELAND
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80538-9071
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-624-4451
Provider Business Mailing Address Fax Number:
970-490-4199

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
311 STEELE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DENVER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80206-4479
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-372-4000
Provider Business Practice Location Address Fax Number:
303-372-4001
Provider Enumeration Date:
02/16/2007

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: 363A00000X , with the licence number:  1539 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 16377044 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004704 . This is a "KAISER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".




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