MEDICARE: LESLEY D LOOPER PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	TL1702	SC

General Provider Information

NPI Number	:	1386920502
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLEY D LOOPER PA

Provider Business Mailing Address
First Line	:	11 ARDEN ST
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29607-1704
Country	:	US
Telephone Number	:	864-784-3442
Fax Number	:

Provider Business Practice Location Address
First Line	:	309 W BUTLER RD
Second Line	:
City	:	MAULDIN
State	:	SC
Zip	:	29662-2531
Country	:	US
Telephone Number	:	864-297-1575
Fax Number	:	864-297-6256

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/02/2011
Last Update Date	:	11/15/2011

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