Healthcare Provider Details

I. General information

NPI: 1578504379
Provider Name (Legal Business Name): MARKETA KYNCL LEISURE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 01/13/2023
Certification Date: 01/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 UNIVERSITY AVE
SACRAMENTO CA
95825-6708
US

IV. Provider business mailing address

755 UNIVERSITY AVE
SACRAMENTO CA
95825-6708
US

V. Phone/Fax

Practice location:
  • Phone: 916-924-8754
  • Fax: 916-924-1739
Mailing address:
  • Phone: 916-924-8754
  • Fax: 916-924-1739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101044383
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number220519
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: