Healthcare Provider Details

I. General information

NPI: 1669006508
Provider Name (Legal Business Name): LEAH NICOLE QUACH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LEAH NICOLE DE JESUS PA-C

II. Dates (important events)

Enumeration Date: 03/01/2020
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1027 46TH AVE
LONG ISLAND CITY NY
11101-5245
US

IV. Provider business mailing address

9106 68TH AVE
FOREST HILLS NY
11375-5724
US

V. Phone/Fax

Practice location:
  • Phone: 212-385-3700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number025158
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: