Basic Information
| Provider Information | |||||||||
| NPI: | 1982320610 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCDONALD | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2313 MAYAPPLE CT | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320685322 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1564 KINGSLEY AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320734521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042648801 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2022 | ||||||||
| LastUpdateDate: | 10/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.