Healthcare Provider Details

I. General information

NPI: 1467724591
Provider Name (Legal Business Name): MISTY BASHAM-LEEDY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2012
Last Update Date: 09/29/2021
Certification Date: 09/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 BELLEVIEW AVE SE CARILION RMH - DEPARTMENT OF EMERGENCY MEDICINE
ROANOKE VA
24014-1838
US

IV. Provider business mailing address

1906 BELLEVIEW AVENUE CARILION RMH - DEPARTMENT OF EMERGENCY MEDICINE
ROANOKE VA
24014
US

V. Phone/Fax

Practice location:
  • Phone: 540-266-6331
  • Fax: 540-981-9550
Mailing address:
  • Phone: 540-266-6331
  • Fax: 540-981-9550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110003761
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: