| Doctor Name: | MR. LORIN LEITHEAD |
| NPI Number: | 1164852745 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | APRN |
| License Number: | 312206-4405 |
| Business Practice Address: | 4095 E Pony Express Pkwy Suite 1 Eagle Mountain, UT - 840055529 |
| Business Phone Number: | 8014298037 |
| Business Fax Number: | 8017537476 |
| Mailing Address: | 1055 N 500 W Attn: Credentialing, PROVO |
| State: | UT |
| Postal Code: | 846043305 |
| Phone Number: | 8013548225 |
| Fax Number: | 8014180941 |
| NPI Enumeration Date: | 11/19/2013 |
| NPI Last Update Date: | 05/09/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LF0000X |
| License Number: | 312206-4405 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | UT |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Family |
| Taxonomy Definition: | |