Healthcare Provider Details

I. General information

NPI: 1639652472
Provider Name (Legal Business Name): MEGAN KENDRA LEASK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEGAN KENDRA HAVENER PA

II. Dates (important events)

Enumeration Date: 09/07/2018
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR
LEBANON NH
03756-0001
US

IV. Provider business mailing address

1 MEDICAL CENTER DR
LEBANON NH
03756-0001
US

V. Phone/Fax

Practice location:
  • Phone: 603-629-1793
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1419
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: