1639208580 NPI number — SARAH J LEET P.A.

Table of content: SARAH J LEET P.A. (NPI 1639208580)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639208580 NPI number — SARAH J LEET P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEET
Provider First Name:
SARAH
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.
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:
1639208580
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 SW COLUMBIA ST STE 6210
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97702-1099
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-383-3005
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
535 NORTH REED ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SISTERS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97759
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-383-3005
Provider Business Practice Location Address Fax Number:
541-383-1883
Provider Enumeration Date:
03/05/2007

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: 363AM0700X , with the licence number:  PA10003942 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA215926 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8359432 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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