Healthcare Provider Details

I. General information

NPI: 1548883077
Provider Name (Legal Business Name): NICHOLAS LEHAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2020
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date: 07/25/2023
Reactivation Date: 08/09/2023

III. Provider practice location address

13395 N MARANA MAIN ST
MARANA AZ
85653-7008
US

IV. Provider business mailing address

PO BOX 188
MARANA AZ
85653-0188
US

V. Phone/Fax

Practice location:
  • Phone: 520-682-4111
  • Fax: 520-682-3817
Mailing address:
  • Phone: 520-682-4111
  • Fax: 520-682-3817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number10375
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: