Basic Information
| Provider Information | |||||||||
| NPI: | 1487619680 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AVERY | ||||||||
| FirstName: | LEANNE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2920 HIGHWOODS BLVD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276040010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774984490 | ||||||||
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| Practice Location | |||||||||
| Address1: | 222 ASHVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275186130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198591136 | ||||||||
| FaxNumber: | 9198594240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 02/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 103187 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1487619680 | 05 | NC | MEDICAID |