Healthcare Provider Details

I. General information

NPI: 1134113905
Provider Name (Legal Business Name): LEAH W. BROCKWAY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 02/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 MEDICAL GROUP/ FLIGHT MEDICINE CLINIC 700 HOSPITAL LOOP, BLDG 9000
FAIRCHILD AFB WA
99011
US

IV. Provider business mailing address

1614 S LINCOLN ST
SPOKANE WA
99203-1053
US

V. Phone/Fax

Practice location:
  • Phone: 509-247-5755
  • Fax: 509-247-8833
Mailing address:
  • Phone: 509-995-3307
  • Fax: 509-747-4234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5279439-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License NumberMD00041103
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number11633
License Number StateAL
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number17373
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: