Provider Demographics
NPI:1992818504
Name:LEACH, MICHAEL DAVID (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:LEACH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6716 NW 11TH PLACE
Mailing Address - Street 2:STE 200
Mailing Address - City:GAINEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4215
Mailing Address - Country:US
Mailing Address - Phone:352-331-9729
Mailing Address - Fax:407-895-3608
Practice Address - Street 1:6716 NW 11TH PLACE
Practice Address - Street 2:STE 200
Practice Address - City:GAINEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4215
Practice Address - Country:US
Practice Address - Phone:352-331-9729
Practice Address - Fax:407-895-3608
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103759363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY04QNOtherBCBS FL
FL002619000Medicaid
FLU8326SMedicare PIN
FLU8326RMedicare PIN