Provider Demographics
NPI:1760790612
Name:BROWN, LESLIE N (PA)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:N
Last Name:BROWN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:
Other - Last Name:GRIFFINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:79 WAWECUS ST
Mailing Address - Street 2:STE. 101
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2160
Mailing Address - Country:US
Mailing Address - Phone:860-886-2655
Mailing Address - Fax:860-886-2655
Practice Address - Street 1:79 WAWECUS ST
Practice Address - Street 2:STE. 101
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2160
Practice Address - Country:US
Practice Address - Phone:860-886-2655
Practice Address - Fax:860-886-2655
Is Sole Proprietor?:No
Enumeration Date:2010-09-14
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002505363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008030891Medicaid
9705626OtherAETNA
CT008030891Medicaid