Healthcare Provider Details

I. General information

NPI: 1699295543
Provider Name (Legal Business Name): KENNETH TYLER LEAPHART PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2017
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N ELM ST
GREENSBORO NC
27401-1004
US

IV. Provider business mailing address

123 PIEDMONT AVE APT D
WINSTON SALEM NC
27101-3667
US

V. Phone/Fax

Practice location:
  • Phone: 336-207-7005
  • Fax:
Mailing address:
  • Phone: 803-760-0859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number001007324
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-07324
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: