Provider Demographics
NPI:1538349030
Name:LESLIE CANYON FAMILY MEDICINE, P.S.
Entity type:Organization
Organization Name:LESLIE CANYON FAMILY MEDICINE, P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDIENT / CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LUCIEN
Authorized Official - Middle Name:T
Authorized Official - Last Name:MEGNA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-628-2331
Mailing Address - Street 1:705 GAGE BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-9701
Mailing Address - Country:US
Mailing Address - Phone:509-628-2331
Mailing Address - Fax:509-628-0537
Practice Address - Street 1:705 GAGE BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-9701
Practice Address - Country:US
Practice Address - Phone:509-628-2331
Practice Address - Fax:509-628-0537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWA00034155208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7077993Medicaid
11151316OtherCAQH
11151316OtherCAQH