Basic Information
| Provider Information | |||||||||
| NPI: | 1841365632 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIOTT | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | RENE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2379 | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411052379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064086200 | ||||||||
| FaxNumber: | 6064086612 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 S LIMESTONE | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405060007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593235901 | ||||||||
| FaxNumber: | 8593233040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 08/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA980 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | PA980 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | PA980 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 000000512514 | 01 | KY | ANTHEM BCBS | OTHER | P00454184 | 01 | KY | RAILROAD MEDICARE PTAN | OTHER | DB9578 | 01 | KY | RAILROAD MEDICARE GROUP | OTHER | 7100032550 | 05 | KY | MEDICAID |