Basic Information
| Provider Information | |||||||||
| NPI: | 1902825417 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EVERETT | ||||||||
| FirstName: | LEIGH | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7250 PARKWAY DRIVE | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | HANOVER | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4439490814 | ||||||||
| FaxNumber: | 4432926814 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 KINGSLEY LN | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235054614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7578895735 | ||||||||
| FaxNumber: | 7578895742 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 10/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0110840858 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 278246 | 01 | VA | ANTHEM | OTHER | ME0806820 | 01 | DEA CERTIFICATE | OTHER | MF0806832 | 01 | DEA CERTIFICATE | OTHER | 212140900 | 05 | MD | MEDICAID |