Provider Demographics
NPI:1962733808
Name:LEACH, ERIC WAYNE (PA-C)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:WAYNE
Last Name:LEACH
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:PO BOX 4930
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74159-0930
Mailing Address - Country:US
Mailing Address - Phone:918-747-4975
Mailing Address - Fax:918-743-8552
Practice Address - Street 1:5801 E 41ST ST STE 900
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-5631
Practice Address - Country:US
Practice Address - Phone:918-747-4975
Practice Address - Fax:918-743-8552
Is Sole Proprietor?:No
Enumeration Date:2010-01-15
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1871363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200279490AMedicaid
OK341927YY8BMedicare PIN