Provider Demographics
NPI:1740262856
Name:DISHAW, LESLEY S (PAC)
Entity type:Individual
Prefix:
First Name:LESLEY
Middle Name:S
Last Name:DISHAW
Suffix:
Gender:F
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:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7226
Mailing Address - Fax:920-445-7229
Practice Address - Street 1:1010 OLIVE AVE
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:WI
Practice Address - Zip Code:54121-0380
Practice Address - Country:US
Practice Address - Phone:800-380-7411
Practice Address - Fax:715-528-5592
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1236023363A00000X
MI5601003358363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI970028140OtherRR MEDICARE
MI0852210330OtherBCBS MI
WI41927000Medicaid
MI970028140OtherRR MEDICARE
MIP22579Medicare UPIN
MIP17840011Medicare PIN