Provider Demographics
NPI:1629012927
Name:WILCOXSON, LESLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:LESLEY
Middle Name:
Last Name:WILCOXSON
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 1:1020 STAGSHAW LN
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-1077
Mailing Address - Country:US
Mailing Address - Phone:423-246-8082
Mailing Address - Fax:
Practice Address - Street 1:1020 STAGSHAW LN
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-1077
Practice Address - Country:US
Practice Address - Phone:423-246-8082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36231207P00000X
VA0101240639207P00000X
NC2007-00581207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010186366Medicaid
VA010186366Medicaid
TN3332900Medicare ID - Type Unspecified