Provider Demographics
NPI:1386920502
Name:LOOPER, LESLEY D (PA)
Entity type:Individual
Prefix:
First Name:LESLEY
Middle Name:D
Last Name:LOOPER
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 1:11 ARDEN ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-1704
Mailing Address - Country:US
Mailing Address - Phone:864-784-3442
Mailing Address - Fax:
Practice Address - Street 1:309 W BUTLER RD
Practice Address - Street 2:
Practice Address - City:MAULDIN
Practice Address - State:SC
Practice Address - Zip Code:29662-2531
Practice Address - Country:US
Practice Address - Phone:864-297-1575
Practice Address - Fax:864-297-6256
Is Sole Proprietor?:No
Enumeration Date:2011-11-02
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL1702363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical