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General NPI Number Information
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NPI Number | 1740262856
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Entity Type | Individual
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Provider Name | LESLEY S DISHAW PAC
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Gender | Female
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Dates
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Enumeration Date | 11/15/2005
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Last Update Date | 09/30/2020
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Provider Practice Location Address
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Address Line | 1010 OLIVE AVE
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City | FLORENCE
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State | WI
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Zip | 54121-0380
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Country | US
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Telephone | 800-380-7411
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Fax | 715-528-5592
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Provider Business Mailing Address
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Address Line | PO BOX 22487
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City | GREEN BAY
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State | WI
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Zip | 54305-2487
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Country | US
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Telephone | 920-445-7226
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Fax | 920-445-7229
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 1236023
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 5601003358
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License Number State | MI
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