=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407411275
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TORIE KATELIN LESLIE PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2019
-----------------------------------------------------
Last Update Date | 10/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3350 GRATIOT BLVD STE A
-----------------------------------------------------
City | MARYSVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48040-2121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-364-4000
-----------------------------------------------------
Fax | 810-364-4000
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3050 COMMERCE DR
-----------------------------------------------------
City | FORT GRATIOT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48059-3819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-385-4441
-----------------------------------------------------
Fax | 810-385-4965
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 5601009463
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA12778
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------