Provider Demographics
NPI:1730141987
Name:GOODAVISH, LESLIE L (MMS PAC)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:L
Last Name:GOODAVISH
Suffix:
Gender:F
Credentials:MMS PAC
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:L
Other - Last Name:STANDORF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MMS PAC
Mailing Address - Street 1:7974 UW HEALTH CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5531
Mailing Address - Country:US
Mailing Address - Phone:608-829-5485
Mailing Address - Fax:
Practice Address - Street 1:4602 EASTPARK BLVD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53718-2002
Practice Address - Country:US
Practice Address - Phone:608-263-8820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-PAC-LIC-79429363A00000X
WI1933-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant