Provider Demographics
NPI:1063416089
Name:PANUS, LESLIE WEYLON (MD)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:WEYLON
Last Name:PANUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 WOODLAWN DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-5978
Mailing Address - Country:US
Mailing Address - Phone:423-929-7168
Mailing Address - Fax:423-928-9625
Practice Address - Street 1:107 WOODLAWN DR
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-5978
Practice Address - Country:US
Practice Address - Phone:423-929-7168
Practice Address - Fax:423-928-9625
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD27541207RN0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3098628Medicaid
TN3098628Medicaid
TN3098628Medicare PIN