Provider Demographics
NPI:1912159153
Name:PHOENIX, LEIGH RYAN (PA-C)
Entity type:Individual
Prefix:
First Name:LEIGH
Middle Name:RYAN
Last Name:PHOENIX
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 1:952 RIDGEFIELD CT
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-2531
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:39000 7 MILE RD STE 1400
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1006
Practice Address - Country:US
Practice Address - Phone:947-523-4310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007012363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000508200Medicaid
P00685858Medicare PIN
FLAX644YMedicare PIN
FLAX644XMedicare PIN
FLAX644ZMedicare PIN