Basic Information
| Provider Information | |||||||||
| NPI: | 1386940518 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEITZ | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 705 DIXIE ST | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301173818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708369666 | ||||||||
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| Practice Location | |||||||||
| Address1: | 705 DIXIE ST | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301173818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708369666 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2011 | ||||||||
| LastUpdateDate: | 02/26/2011 | ||||||||
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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 | 363AM0700X | 006051 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 006051 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.