Provider Demographics
NPI:1841365632
Name:ELLIOTT, LESLIE RENE (PA-C)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:RENE
Last Name:ELLIOTT
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:PO BOX 2379
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-2379
Mailing Address - Country:US
Mailing Address - Phone:606-408-6200
Mailing Address - Fax:606-408-6612
Practice Address - Street 1:1000 S LIMESTONE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40506-0007
Practice Address - Country:US
Practice Address - Phone:859-323-5901
Practice Address - Fax:859-323-3040
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA980363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000512514OtherANTHEM BCBS
KYP00454184OtherRAILROAD MEDICARE PTAN
KYDB9578OtherRAILROAD MEDICARE GROUP
KY7100032550Medicaid
KY0930302Medicare PIN
KYQ75741Medicare UPIN