Provider Demographics
NPI:1649244120
Name:MADORE, LESLIE (PA)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:MADORE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9720 S 1300 E
Mailing Address - Street 2:SUITE E230
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-3712
Mailing Address - Country:US
Mailing Address - Phone:801-501-2950
Mailing Address - Fax:801-501-2951
Practice Address - Street 1:9720 SOUTH 1300 EAST
Practice Address - Street 2:SUITE E230
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094
Practice Address - Country:US
Practice Address - Phone:801-501-2950
Practice Address - Fax:801-501-2951
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9377430-1206363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP79727Medicare UPIN
CT970002001Medicare ID - Type Unspecified