Healthcare Provider Details

I. General information

NPI: 1124102009
Provider Name (Legal Business Name): LEIGH WYNKOOP PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 03/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4205 BEN FRANKLIN BLVD
DURHAM NC
27704-2143
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 919-477-6900
  • Fax: 919-477-5081
Mailing address:
  • Phone: 919-477-6900
  • Fax: 919-477-5081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number001000258
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-00258
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: