=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336953579
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ZOE ANN LEEFER VAN LEEUWEN PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2025
-----------------------------------------------------
Last Update Date | 11/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 414 G ST STE 112
-----------------------------------------------------
City | MARYSVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95901-5669
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-749-6650
-----------------------------------------------------
Fax | 530-749-6651
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 240 NATOMA STATION DR APT 138
-----------------------------------------------------
City | FOLSOM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95630-7983
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-798-8045
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 67236
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------