Provider Demographics
NPI:1194132746
Name:BUSH, LESLIE ANN (PA-C)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:ANN
Last Name:BUSH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 N SAINT CLAIR ST STE 20-100
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-5970
Mailing Address - Country:US
Mailing Address - Phone:312-695-1920
Mailing Address - Fax:312-695-5747
Practice Address - Street 1:675 N SAINT CLAIR ST STE 20-100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5970
Practice Address - Country:US
Practice Address - Phone:312-695-1920
Practice Address - Fax:312-695-5747
Is Sole Proprietor?:No
Enumeration Date:2014-07-15
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085005060363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant