Basic Information
| Provider Information | |||||||||
| NPI: | 1164523197 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUFFMAN-DILG | ||||||||
| FirstName: | LESLEY | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | HUFFMAN | ||||||||
| OtherFirstName: | LESLEY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12655 OLIVE BLVD STE 400 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631416386 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148511075 | ||||||||
| FaxNumber: | 3148514477 | ||||||||
| Practice Location | |||||||||
| Address1: | 13303 TESSON FERRY RD STE 45 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631284062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147485917 | ||||||||
| FaxNumber: | 3147485919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 2005004539 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 196559 | 01 | BLUE CROSS OF MO | OTHER |