Provider Demographics
NPI:1568695062
Name:ROBERTS, LESLEY SUSANNE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LESLEY
Middle Name:SUSANNE
Last Name:ROBERTS
Suffix:
Gender:F
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 1:913 W CANFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-9764
Mailing Address - Country:US
Mailing Address - Phone:208-217-2529
Mailing Address - Fax:208-262-7461
Practice Address - Street 1:913 W CANFIELD AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-9764
Practice Address - Country:US
Practice Address - Phone:208-819-7103
Practice Address - Fax:208-719-0050
Is Sole Proprietor?:No
Enumeration Date:2009-08-31
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1508363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1568695062Medicaid