Healthcare Provider Details

I. General information

NPI: 1649628439
Provider Name (Legal Business Name): LESLIE SHOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2016
Last Update Date: 04/03/2023
Certification Date: 04/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3220 BLUFF CREEK DR
COLUMBIA MO
65201-3663
US

IV. Provider business mailing address

3220 BLUFF CREEK DR
COLUMBIA MO
65201-3663
US

V. Phone/Fax

Practice location:
  • Phone: 573-224-8200
  • Fax:
Mailing address:
  • Phone: 573-224-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number2016017558
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: