1265441703 NPI number — LESLIE A PRICE PA-C

Table of content: LESLIE A PRICE PA-C (NPI 1265441703)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265441703 NPI number — LESLIE A PRICE PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRICE
Provider First Name:
LESLIE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265441703
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5943 STADIUM DR
Provider Second Line Business Mailing Address:
STE 1
Provider Business Mailing Address City Name:
KALAMAZOO
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49009-3016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-552-2836
Provider Business Mailing Address Fax Number:
269-552-2964

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7775 ANGLING RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTAGE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49024-7427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-321-7120
Provider Business Practice Location Address Fax Number:
269-321-7154
Provider Enumeration Date:
08/05/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  50.002183 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 5601007305 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)