MEDICARE: LESLIE C TREGILLUS MD

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	207Q00000X	Family Medicine Physician	MD00023288	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477638716
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE C TREGILLUS MD

Provider Business Mailing Address
First Line	:	1003 KOALA DR
Second Line	:
City	:	OMAK
State	:	WA
Zip	:	98841-9247
Country	:	US
Telephone Number	:	509-422-5700
Fax Number	:	855-204-8902

Provider Business Practice Location Address
First Line	:	1003 KOALA DR
Second Line	:
City	:	OMAK
State	:	WA
Zip	:	98841-9247
Country	:	US
Telephone Number	:	509-422-5700
Fax Number	:	855-204-8902

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

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	05/23/2022

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