MEDICARE: NICHOLAS LEAVER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	13886	NV

General Provider Information

NPI Number	:	1306138722
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS LEAVER

Provider Business Mailing Address
First Line	:	400 W 128TH ST APT 53A
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10027-2858
Country	:	US
Telephone Number	:	646-409-7579
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 W 128TH ST APT 53A
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10027-2858
Country	:	US
Telephone Number	:	646-409-7579
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2011
Last Update Date	:	05/03/2011

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Directions to “ NICHOLAS LEAVER ” Practice Location

Language	Start Address	Practice Location

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