Basic Information
| Provider Information | |||||||||
| NPI: | 1356556906 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEISURE | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1363W SPRUCE AVE | ||||||||
| Address2: | |||||||||
| City: | WASILLA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996545327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073762411 | ||||||||
| FaxNumber: | 9073523363 | ||||||||
| Practice Location | |||||||||
| Address1: | 108 6TH ST | ||||||||
| Address2: | |||||||||
| City: | WINFIELD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75493 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035244700 | ||||||||
| FaxNumber: | 9035244900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2007 | ||||||||
| LastUpdateDate: | 07/10/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA00032 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.