Provider Demographics
NPI:1417161530
Name:ROSS, LESLIE K (PA-C)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:K
Last Name:ROSS
Suffix:
Gender:F
Credentials:PA-C
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1190
Mailing Address - Street 2:SUITE 490
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-1190
Mailing Address - Country:US
Mailing Address - Phone:678-312-5600
Mailing Address - Fax:770-339-2135
Practice Address - Street 1:631 PROFESSIONAL DR
Practice Address - Street 2:SUITE 450
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3367
Practice Address - Country:US
Practice Address - Phone:770-963-8030
Practice Address - Fax:770-339-9577
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2016-09-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA002003363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA97WCJVNMedicare PIN