Provider Demographics
NPI:1164523197
Name:HUFFMAN-DILG, LESLEY (PA)
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:
Last Name:HUFFMAN-DILG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LESLEY
Other - Middle Name:
Other - Last Name:HUFFMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12655 OLIVE BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6386
Mailing Address - Country:US
Mailing Address - Phone:314-851-1075
Mailing Address - Fax:314-851-4477
Practice Address - Street 1:13303 TESSON FERRY RD STE 45
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-4062
Practice Address - Country:US
Practice Address - Phone:314-748-5917
Practice Address - Fax:314-748-5919
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005004539363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
196559OtherBLUE CROSS OF MO
196559OtherBLUE CROSS OF MO
000097205Medicare ID - Type Unspecified