Provider Demographics
NPI:1841805686
Name:COOPER, LESLIE ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:ANN
Last Name:COOPER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 FRIST BLVD STE 4
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-4800
Mailing Address - Country:US
Mailing Address - Phone:772-595-5302
Mailing Address - Fax:772-595-5304
Practice Address - Street 1:2401 FRIST BLVD STE 4
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4800
Practice Address - Country:US
Practice Address - Phone:772-595-5302
Practice Address - Fax:772-595-5304
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPAT9113506363AS0400X
FLPA9113506363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical