Provider Demographics
NPI:1104858927
Name:LEINICKE, TANYA M (MD)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:M
Last Name:LEINICKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3427 E TUDOR RD
Mailing Address - Street 2:STE A
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-1282
Mailing Address - Country:US
Mailing Address - Phone:907-565-8005
Mailing Address - Fax:907-565-8066
Practice Address - Street 1:3200 PROVIDENCE DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4615
Practice Address - Country:US
Practice Address - Phone:907-565-8005
Practice Address - Fax:907-565-8066
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AK5354207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD8572Medicaid
AKMD8572Medicaid
AKH22598Medicare UPIN