Healthcare Provider Details

I. General information

NPI: 1871584417
Provider Name (Legal Business Name): LESTER DARRELL LEGGETTE PA-AA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 06/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 HOSPITAL DR SUITE 410
MACON GA
31217
US

IV. Provider business mailing address

PO BOX 2564
MACON GA
31203-2565
US

V. Phone/Fax

Practice location:
  • Phone: 478-746-5644
  • Fax: 229-434-2502
Mailing address:
  • Phone: 478-746-5644
  • Fax: 478-745-4849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number001796
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: