Provider Demographics
NPI:1689632457
Name:GREGORY, LESLIE DIANE (PAC)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:DIANE
Last Name:GREGORY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8332 SE 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-7102
Mailing Address - Country:US
Mailing Address - Phone:503-595-9300
Mailing Address - Fax:503-595-9301
Practice Address - Street 1:8332 SE 13TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-7102
Practice Address - Country:US
Practice Address - Phone:503-595-9300
Practice Address - Fax:503-595-9301
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00823363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR268490Medicaid
ORP83603Medicare UPIN
OR268490Medicaid