Healthcare Provider Details

I. General information

NPI: 1568095974
Provider Name (Legal Business Name): LESLIE SEMERARO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2020
Last Update Date: 10/12/2021
Certification Date: 10/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 N NEVADA AVE STE 5010
COLORADO SPRINGS CO
80907-6865
US

IV. Provider business mailing address

2222 N NEVADA AVE STE 5010
COLORADO SPRINGS CO
80907-6865
US

V. Phone/Fax

Practice location:
  • Phone: 719-776-6700
  • Fax: 719-776-6780
Mailing address:
  • Phone: 719-776-6700
  • Fax: 719-776-6780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0006960
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: