Provider Demographics
NPI:1720128218
Name:MASHBURN, LESLIE A (PA)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:A
Last Name:MASHBURN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:A
Other - Last Name:GOLDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 71367
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31708-1367
Mailing Address - Country:US
Mailing Address - Phone:229-435-0525
Mailing Address - Fax:229-434-9827
Practice Address - Street 1:2311 LAKE PARK DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-3183
Practice Address - Country:US
Practice Address - Phone:229-435-0525
Practice Address - Fax:229-434-9827
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004946363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical