=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356967236
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MELISSA LEONARD PA-C SURGICAL ASSIST
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2020
-----------------------------------------------------
Last Update Date | 10/18/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7600 N 15TH ST STE 290
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85020-4336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-395-0718
-----------------------------------------------------
Fax | 602-277-8146
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 39179
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85069-9179
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-395-0718
-----------------------------------------------------
Fax | 602-277-8146
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MELISSA LEONARD
-----------------------------------------------------
Credential | PA-C
-----------------------------------------------------
Telephone | 602-395-0718
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------