Provider Demographics
NPI:1124695135
Name:PATRICK, LEIGHTON GARRETT
Entity type:Individual
Prefix:
First Name:LEIGHTON
Middle Name:GARRETT
Last Name:PATRICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 SHILOH RD S
Mailing Address - Street 2:
Mailing Address - City:MEXIA
Mailing Address - State:TX
Mailing Address - Zip Code:76667-3912
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 PHIL AVE
Practice Address - Street 2:
Practice Address - City:WORTHAM
Practice Address - State:TX
Practice Address - Zip Code:76693-4612
Practice Address - Country:US
Practice Address - Phone:254-203-2495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1010747164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX29358294OtherDRIVERS LICENSE