Provider Demographics
NPI:1417093642
Name:DURST, LESSLIE MARQUEZ (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LESSLIE
Middle Name:MARQUEZ
Last Name:DURST
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:LESSLIE
Other - Middle Name:MARQUEZ
Other - Last Name:DURST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:15830 BALLANTYNE MEDICAL PLACE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277
Mailing Address - Country:US
Mailing Address - Phone:704-341-0090
Mailing Address - Fax:704-341-0092
Practice Address - Street 1:15830 BALLANTYNE MEDICAL PLACE
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277
Practice Address - Country:US
Practice Address - Phone:704-341-0090
Practice Address - Fax:704-341-0092
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00785363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant