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General NPI Number Information
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NPI Number | 1629552435
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Entity Type | Individual
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Provider Name | LEENA CHACKO KOSHY PA-C
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Gender | Female
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Dates
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Enumeration Date | 09/18/2018
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Last Update Date | 10/05/2022
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Provider Practice Location Address
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Address Line | 12011 OLD TIMBER RD
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City | CHARLOTTE
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State | NC
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Zip | 28269-8750
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Country | US
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Telephone | 704-574-7216
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Fax |
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Provider Business Mailing Address
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Address Line | 391 GEORGE W LILES PKWY NW
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City | CONCORD
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State | NC
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Zip | 28027-8218
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Country | US
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Telephone | 48-861-7807
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 0010-07927
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License Number State | NC
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