Provider Demographics
NPI:1265441703
Name:PRICE, LESLIE A (PA-C)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:A
Last Name:PRICE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5943 STADIUM DR
Mailing Address - Street 2:STE 1
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-3016
Mailing Address - Country:US
Mailing Address - Phone:269-552-2836
Mailing Address - Fax:269-552-2964
Practice Address - Street 1:7775 ANGLING RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-7427
Practice Address - Country:US
Practice Address - Phone:269-321-7120
Practice Address - Fax:269-321-7154
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.002183363A00000X
MI5601007305363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant