Provider Demographics
NPI:1922084649
Name:LIEGEL, LESLIE P (PAC)
Entity Type:Individual
Prefix:MR
First Name:LESLIE
Middle Name:P
Last Name:LIEGEL
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8814 TIMBER WOLF TRL
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-2721
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8814 TIMBER WOLF TRL
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717-2721
Practice Address - Country:US
Practice Address - Phone:608-827-8358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI819-23363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00144568OtherRAILROAD MEDICARE PROV #
WI70OtherDEANCARE PROV #
WI1009390OtherPHYS PLUS PROV #
WI42950700Medicaid
WI42950700Medicaid
WI70OtherDEANCARE PROV #