Provider Demographics
NPI:1477638716
Name:TREGILLUS, LESLIE C (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:C
Last Name:TREGILLUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 KOALA DR
Mailing Address - Street 2:
Mailing Address - City:OMAK
Mailing Address - State:WA
Mailing Address - Zip Code:98841-9247
Mailing Address - Country:US
Mailing Address - Phone:509-422-5700
Mailing Address - Fax:855-204-8902
Practice Address - Street 1:1003 KOALA DR
Practice Address - Street 2:
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841-9247
Practice Address - Country:US
Practice Address - Phone:509-422-5700
Practice Address - Fax:855-204-8902
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00023288207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1030857Medicaid
A 06825Medicare UPIN
WA1030857Medicaid