Healthcare Provider Details

I. General information

NPI: 1568945400
Provider Name (Legal Business Name): MARIAN LEACH PA-C, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIAN BORNHORST

II. Dates (important events)

Enumeration Date: 09/06/2018
Last Update Date: 06/27/2022
Certification Date: 06/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 NELSON BROGDON BLVD STE 250
BUFORD GA
30518-5415
US

IV. Provider business mailing address

1090 WESTCROFT LN
ROSWELL GA
30075-6020
US

V. Phone/Fax

Practice location:
  • Phone: 770-442-1911
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: