Healthcare Provider Details

I. General information

NPI: 1790696540
Provider Name (Legal Business Name): LESLIE LYNN DICARLO-HACK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2026
Last Update Date: 09/12/2026
Certification Date: 09/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8908 SKYROCK CT
COLUMBIA MD
21046-1418
US

IV. Provider business mailing address

8908 SKYROCK CT
COLUMBIA MD
21046-1418
US

V. Phone/Fax

Practice location:
  • Phone: 410-913-0135
  • Fax: 410-913-0135
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0000074
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: