Basic Information
| Provider Information | |||||||||
| NPI: | 1407947286 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAZAN | ||||||||
| FirstName: | LEANDRA | ||||||||
| MiddleName: | BIBIANA | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PA-C, MT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NOSSA | ||||||||
| OtherFirstName: | LEANDRA | ||||||||
| OtherMiddleName: | BIBIANA | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1900 16TH ST | ||||||||
| Address2: | |||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806315114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703502426 | ||||||||
| FaxNumber: | 9703502478 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 16TH ST | ||||||||
| Address2: | |||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703502426 | ||||||||
| FaxNumber: | 9703502478 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 11/28/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9103879 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA0005128 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 246ZA2600X | TN35171 | FL | N | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Art, Medical |
ID Information
| ID | Type | State | Issuer | Description | 1407947286 | 05 | CO | MEDICAID |