Provider Demographics
NPI:1326244104
Name:MACE, LESLI (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LESLI
Middle Name:
Last Name:MACE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5715
Mailing Address - Fax:540-224-5684
Practice Address - Street 1:1204 FRANKLIN RD SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4606
Practice Address - Country:US
Practice Address - Phone:540-981-1439
Practice Address - Fax:540-345-5446
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00865363A00000X
VA0110003893363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1326244104Medicaid
VA1326244104Medicaid
VAP01217438Medicare PIN