MEDICARE: COURTNEY M. LESLIE PA-C

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	363A00000X	Physician Assistant
2	363A00000X	Physician Assistant	PA10028	TX

General Provider Information

NPI Number	:	1699150375
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COURTNEY M. LESLIE PA-C

Provider Business Mailing Address
First Line	:	3455 LOCKE AVE STE 210
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-5747
Country	:	US
Telephone Number	:	817-529-6200
Fax Number	:	817-529-6206

Provider Business Practice Location Address
First Line	:	3455 LOCKE AVE STE 210
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-5747
Country	:	US
Telephone Number	:	817-529-6200
Fax Number	:

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

Provider Enumeration Date	:	07/23/2015
Last Update Date	:	08/18/2021

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Directions to “ COURTNEY M. LESLIE PA-C” Practice Location

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