Provider Demographics
NPI:1245603265
Name:YEDOR, LESLIE (LAC, PA-C)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:YEDOR
Suffix:
Gender:
Credentials:LAC, 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 953
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-0953
Mailing Address - Country:US
Mailing Address - Phone:805-338-6905
Mailing Address - Fax:
Practice Address - Street 1:180 S FRONTAGE RD W
Practice Address - Street 2:
Practice Address - City:VAIL
Practice Address - State:CO
Practice Address - Zip Code:81657-5038
Practice Address - Country:US
Practice Address - Phone:805-338-6905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-13
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC16735171100000X
COACU.0002343171100000X
CO363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No171100000XOther Service ProvidersAcupuncturist