Provider Demographics
NPI:1396057691
Name:LEIBELSPERGER, EVAN M (PA-C)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:M
Last Name:LEIBELSPERGER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7785 N STATE ST STE 120
Mailing Address - Street 2:
Mailing Address - City:LOWVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13367-1297
Mailing Address - Country:US
Mailing Address - Phone:315-376-4505
Mailing Address - Fax:315-376-4259
Practice Address - Street 1:7785 N STATE ST STE 120
Practice Address - Street 2:
Practice Address - City:LOWVILLE
Practice Address - State:NY
Practice Address - Zip Code:13367-1297
Practice Address - Country:US
Practice Address - Phone:315-376-4505
Practice Address - Fax:315-376-4259
Is Sole Proprietor?:No
Enumeration Date:2010-07-02
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400177609Medicare PIN