Provider Demographics
NPI:1194275099
Name:LATTIN, LESLIE (PA)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:LATTIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:
Other - Last Name:SCHULZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 5204
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-0603
Mailing Address - Country:US
Mailing Address - Phone:623-889-3477
Mailing Address - Fax:623-889-3478
Practice Address - Street 1:750 N ESTRELLA PKWY STE 40
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-9279
Practice Address - Country:US
Practice Address - Phone:623-877-6180
Practice Address - Fax:623-889-3478
Is Sole Proprietor?:No
Enumeration Date:2016-10-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6559363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZMS4062092OtherDEA