Provider Demographics
NPI:1194981860
Name:MCKINNON-LEACH, ESSIE Y (PA)
Entity type:Individual
Prefix:
First Name:ESSIE
Middle Name:Y
Last Name:MCKINNON-LEACH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 ATLANTIC PLACE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2316
Mailing Address - Country:US
Mailing Address - Phone:207-661-6654
Mailing Address - Fax:207-842-7773
Practice Address - Street 1:31 BEACH ST
Practice Address - Street 2:
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072-2810
Practice Address - Country:US
Practice Address - Phone:207-282-1500
Practice Address - Fax:207-282-6606
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA1180363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME434701399Medicaid
ME001299201Medicare PIN
ME001299210Medicare PIN
ME434701399Medicaid