MEDICARE: MR. LELAND WILSON CROSBY P.A., MED

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA00673	TX

General Provider Information

NPI Number	:	1255739595
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LELAND WILSON CROSBY P.A., MED

Provider Business Mailing Address
First Line	:	2350 ATASCOCITA RD
Second Line	:	PAM LYCHNER STATE JAIL
City	:	HUMBLE
State	:	TX
Zip	:	77396-3503
Country	:	US
Telephone Number	:	281-454-5036
Fax Number	:

Provider Business Practice Location Address
First Line	:	2350 ATASCOCITA RD
Second Line	:	PAM LYCHNER STATE JAIL
City	:	HUMBLE
State	:	TX
Zip	:	77396-3503
Country	:	US
Telephone Number	:	281-454-5036
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/19/2014
Last Update Date	:	12/19/2014

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