Provider Demographics
NPI:1801906474
Name:ROSENBLATT-BROWN, LESLIE (PA-C)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:ROSENBLATT-BROWN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 HIGHWAY 54 W
Mailing Address - Street 2:SUITE 201
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4549
Mailing Address - Country:US
Mailing Address - Phone:770-461-3776
Mailing Address - Fax:770-461-3565
Practice Address - Street 1:1275 HIGHWAY 54 W
Practice Address - Street 2:SUITE 201
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4549
Practice Address - Country:US
Practice Address - Phone:770-461-3776
Practice Address - Fax:770-461-3565
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3987363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10033138OtherAMERIGROUP
GA319981OtherWELLCARE
GA451479533AMedicaid
GA451479533AMedicaid
GA97WCDQXMedicare PIN