Healthcare Provider Details

I. General information

NPI: 1841365632
Provider Name (Legal Business Name): LESLIE RENE ELLIOTT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 08/01/2022
Certification Date: 08/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 S LIMESTONE
LEXINGTON KY
40506-0007
US

IV. Provider business mailing address

PO BOX 2379
ASHLAND KY
41105-2379
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-5901
  • Fax: 859-323-3040
Mailing address:
  • Phone: 606-408-6200
  • Fax: 606-408-6612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA980
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA980
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA980
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: