Provider Demographics
NPI:1194726901
Name:WILLCOX, LESLIE K (PA C)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:K
Last Name:WILLCOX
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 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:8 JUSTICE LN
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-2354
Practice Address - Country:US
Practice Address - Phone:864-260-9910
Practice Address - Fax:864-260-0209
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1418363A00000X, 363AS0400X
OH50-00-0523363A00000X
IN10000174A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
970027633OtherRAILROAD MEDICARE #
SC0833PAMedicaid