Provider Demographics
NPI:1124865209
Name:VIDAL, LEAH MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:MARIE
Last Name:VIDAL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 FIRST VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-9495
Mailing Address - Country:US
Mailing Address - Phone:321-591-9367
Mailing Address - Fax:
Practice Address - Street 1:5 FIRST VILLAGE DR
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-9495
Practice Address - Country:US
Practice Address - Phone:910-295-6831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-15
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-14407207VG0400X
NC363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology