Healthcare Provider Details

I. General information

NPI: 1831184712
Provider Name (Legal Business Name): LESLIE JEAN MCGOVERN PA-C, MHE, ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 07/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HOSPITAL WAY
POCATELLO ID
83201-5175
US

IV. Provider business mailing address

PO BOX 15070
SCOTTSDALE AZ
85267-5070
US

V. Phone/Fax

Practice location:
  • Phone: 480-421-9700
  • Fax: 480-421-9899
Mailing address:
  • Phone: 480-421-9700
  • Fax: 480-421-9899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA868
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA868
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: