Provider Demographics
NPI:1922069798
Name:LESHOCK, RICHARD (PA-C)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:LESHOCK
Suffix:
Gender:M
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:PO BOX 440210
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37244-0210
Mailing Address - Country:US
Mailing Address - Phone:336-714-6400
Mailing Address - Fax:336-714-6402
Practice Address - Street 1:160 KIMEL FOREST DR
Practice Address - Street 2:STE 100
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6074
Practice Address - Country:US
Practice Address - Phone:336-714-6400
Practice Address - Fax:336-714-6402
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2017-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NC101322363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2742667AMedicare PIN
S25559Medicare UPIN