MEDICARE: LESLIE JEAN MCGOVERN PA-C, MHE, ATC, LAT

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	2255A2300X	Athletic Trainer
2	363AS0400X	Surgical Physician Assistant	PA868	ID
3	363AM0700X	Medical Physician Assistant	PA868	ID

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00902985	OTHER		RAILROAD MEDICARE

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	:	1831184712
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE JEAN MCGOVERN PA-C, MHE, ATC, LAT

Provider Business Mailing Address
First Line	:	PO BOX 15070
Second Line	:
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85267-5070
Country	:	US
Telephone Number	:	480-421-9700
Fax Number	:	480-421-9899

Provider Business Practice Location Address
First Line	:	777 HOSPITAL WAY
Second Line	:
City	:	POCATELLO
State	:	ID
Zip	:	83201-5175
Country	:	US
Telephone Number	:	480-421-9700
Fax Number	:	480-421-9899

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

Provider Enumeration Date	:	09/15/2005
Last Update Date	:	07/19/2011

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Directions to “ LESLIE JEAN MCGOVERN PA-C, MHE, ATC, LAT” Practice Location

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