Provider Demographics
NPI:1699720763
Name:LEACH, MARK JONATHON (PA-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:JONATHON
Last Name:LEACH
Suffix:
Gender:M
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 1:600 VILLAGE SQUARE XING
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-4542
Mailing Address - Country:US
Mailing Address - Phone:561-694-9493
Mailing Address - Fax:561-694-9064
Practice Address - Street 1:600 VILLAGE SQUARE XING
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-4542
Practice Address - Country:US
Practice Address - Phone:561-694-9493
Practice Address - Fax:561-694-9064
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101548207N00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P28823Medicare UPIN
FLE5327YMedicare ID - Type Unspecified
FLE5327XMedicare ID - Type Unspecified
P28823Medicare UPIN
FLE5327AMedicare ID - Type Unspecified
FLE5327WMedicare ID - Type Unspecified