Provider Demographics
NPI:1821649781
Name:PRICE, LESLIE BLAKE (PA)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:BLAKE
Last Name:PRICE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:L.
Other - Middle Name:BLAKE
Other - Last Name:PRICE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:1600 ACCELERATOR WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-3078
Mailing Address - Country:US
Mailing Address - Phone:865-546-2663
Mailing Address - Fax:865-546-9047
Practice Address - Street 1:1600 ACCELERATOR WAY STE 200
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-3078
Practice Address - Country:US
Practice Address - Phone:865-546-2663
Practice Address - Fax:865-546-9047
Is Sole Proprietor?:No
Enumeration Date:2019-09-23
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3969363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ007091Medicaid