Healthcare Provider Details

I. General information

NPI: 1003168683
Provider Name (Legal Business Name): SEAN WILLIAM LEAHY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2012
Last Update Date: 05/07/2020
Certification Date: 05/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1367 WASHINGTON AVE STE 200
ALBANY NY
12206-1048
US

IV. Provider business mailing address

1367 WASHINGTON AVE STE 200
ALBANY NY
12206-1048
US

V. Phone/Fax

Practice location:
  • Phone: 518-489-2999
  • Fax: 518-489-5933
Mailing address:
  • Phone: 518-489-2999
  • Fax: 518-489-5933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number019983
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: