Provider Demographics
NPI:1477608099
Name:LESLIE, DARIN (PA-C)
Entity Type:Individual
Prefix:DR
First Name:DARIN
Middle Name:
Last Name:LESLIE
Suffix:
Gender:M
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 1:689 E 700 N
Mailing Address - Street 2:
Mailing Address - City:FIRTH
Mailing Address - State:ID
Mailing Address - Zip Code:83236-1117
Mailing Address - Country:US
Mailing Address - Phone:208-346-6718
Mailing Address - Fax:208-552-7521
Practice Address - Street 1:2375 CORONADO ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7407
Practice Address - Country:US
Practice Address - Phone:208-522-4600
Practice Address - Fax:208-552-7521
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-514363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1666270Medicare ID - Type UnspecifiedMEDICARE