Provider Demographics
NPI:1699087692
Name:LEESE, CARRIE LYNN (PA-C)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:LYNN
Last Name:LEESE
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 1:1421 FISHBURN RD
Mailing Address - Street 2:
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-9795
Mailing Address - Country:US
Mailing Address - Phone:717-533-2224
Mailing Address - Fax:717-533-2164
Practice Address - Street 1:1421 FISHBURN RD
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-9795
Practice Address - Country:US
Practice Address - Phone:717-533-2224
Practice Address - Fax:717-533-2164
Is Sole Proprietor?:No
Enumeration Date:2010-07-07
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054383363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMA054383OtherMEDICAL LICENSE