MEDICARE: LESLIE MADORE PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	9377430-1206	UT

General Provider Information

NPI Number	:	1649244120
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE MADORE PA

Provider Business Mailing Address
First Line	:	9720 S 1300 E
Second Line	:	SUITE E230
City	:	SANDY
State	:	UT
Zip	:	84094-3712
Country	:	US
Telephone Number	:	801-501-2950
Fax Number	:	801-501-2951

Provider Business Practice Location Address
First Line	:	9720 SOUTH 1300 EAST
Second Line	:	SUITE E230
City	:	SANDY
State	:	UT
Zip	:	84094
Country	:	US
Telephone Number	:	801-501-2950
Fax Number	:	801-501-2951

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/14/2006
Last Update Date	:	01/22/2016

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Directions to “ LESLIE MADORE PA” Practice Location

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