Healthcare Provider Details

I. General information

NPI: 1376051615
Provider Name (Legal Business Name): LESLIE CAROL TAYLOR PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2018
Last Update Date: 05/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9550 ROCKY RIVER RD STE 100
HARRISBURG NC
28075
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-316-3612
  • Fax: 704-316-3613
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-07866
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: