Provider Demographics
NPI:1154808053
Name:LEEPER, VIRGINIA MARIE BRUDER (PA-C)
Entity type:Individual
Prefix:MRS
First Name:VIRGINIA
Middle Name:MARIE BRUDER
Last Name:LEEPER
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 1:3024 E EMPIRE ST STE EANDF
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-5402
Mailing Address - Country:US
Mailing Address - Phone:309-451-3376
Mailing Address - Fax:309-452-3376
Practice Address - Street 1:11110 MEDICAL CAMPUS RD STE 125
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-6799
Practice Address - Country:US
Practice Address - Phone:301-714-4335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-24
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC00006851363AS0400X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085.008214OtherPHYSICIAN ASSISTANT