Provider Demographics
NPI:1730278920
Name:LESLIE, SHANNA MOORE (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANNA
Middle Name:MOORE
Last Name:LESLIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SHANNA
Other - Middle Name:KARI
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:225 MEDICAL CENTER DR STE 101
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-7934
Mailing Address - Country:US
Mailing Address - Phone:270-441-4357
Mailing Address - Fax:
Practice Address - Street 1:225 MEDICAL CENTER DR STE 101
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-7934
Practice Address - Country:US
Practice Address - Phone:270-441-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41554207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK247560OtherMEDICARE PTAN
KY7100041410Medicaid
KYK247560OtherMEDICARE PTAN