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General NPI Number Information
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NPI Number | 1659017499
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Entity Type | Organization
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Legal Business Name | LEADING EDGE HEALTHCARE, PLLC
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Dates
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Enumeration Date | 05/05/2022
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Last Update Date | 03/22/2023
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Provider Practice Location Address
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Address Line | 724 N MONTEZUMA ST STE A
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City | PRESCOTT
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State | AZ
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Zip | 86301-2066
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Country | US
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Telephone | 928-925-2871
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Fax |
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Provider Business Mailing Address
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Address Line | 2182 MARK AVE
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City | PRESCOTT
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State | AZ
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Zip | 86301-1029
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER MEMBER
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Name | JACOB KIRKEENG
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Credential | PA-C
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Telephone | 928-925-2871
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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