Provider Demographics
NPI:1831184712
Name:MCGOVERN, LESLIE JEAN (PA-C, MHE, ATC, LAT)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:JEAN
Last Name:MCGOVERN
Suffix:
Gender:F
Credentials:PA-C, MHE, ATC, LAT
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 15070
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85267-5070
Mailing Address - Country:US
Mailing Address - Phone:480-421-9700
Mailing Address - Fax:480-421-9899
Practice Address - Street 1:777 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5175
Practice Address - Country:US
Practice Address - Phone:480-421-9700
Practice Address - Fax:480-421-9899
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
IDPA868363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1831184712Medicaid
P00902985OtherRAILROAD MEDICARE
1667785Medicare PIN
ID16677852Medicare PIN
16677851Medicare PIN