Provider Demographics
NPI:1861594350
Name:MOON, LESLIE DENISE (PA)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:DENISE
Last Name:MOON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4230 STRINGTOWN RD NE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-8012
Mailing Address - Country:US
Mailing Address - Phone:740-777-7880
Mailing Address - Fax:
Practice Address - Street 1:420 N JAMES RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-1834
Practice Address - Country:US
Practice Address - Phone:614-257-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-04
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50000358363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical