Provider Demographics
NPI:1124090410
Name:LEIBOW, EMILY BARTZEN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:BARTZEN
Last Name:LEIBOW
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:EMILY
Other - Middle Name:FLINT
Other - Last Name:BARTZEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4380 ZIEGLER RD
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-9631
Mailing Address - Country:US
Mailing Address - Phone:970-237-7550
Mailing Address - Fax:970-237-7551
Practice Address - Street 1:4380 ZIEGLER RD
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-9631
Practice Address - Country:US
Practice Address - Phone:970-237-7550
Practice Address - Fax:970-237-7551
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14567363AM0700X
CO3084363AM0700X
COPA.0003084363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO57537771Medicaid
COP01084730OtherRAILROAD MEDICARE
S57347Medicare UPIN
CAS57347Medicare UPIN
COCOA105779Medicare PIN
CAWPA14567BMedicare PIN