Provider Demographics
NPI:1205699550
Name:LESCHACK, ELENA CATHERINE
Entity type:Individual
Prefix:
First Name:ELENA
Middle Name:CATHERINE
Last Name:LESCHACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 SUTTON RD S
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-8439
Mailing Address - Country:US
Mailing Address - Phone:803-547-3800
Mailing Address - Fax:
Practice Address - Street 1:601 SUTTON RD S STE 201
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-8439
Practice Address - Country:US
Practice Address - Phone:803-547-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-31
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC5526363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program