Provider Demographics
NPI:1487726501
Name:PETOSA, LESLIE M (PAAA)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:M
Last Name:PETOSA
Suffix:
Gender:F
Credentials:PAAA
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:M
Other - Last Name:DEAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAAA
Mailing Address - Street 1:PO BOX 932925
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-2925
Mailing Address - Country:US
Mailing Address - Phone:800-364-9216
Mailing Address - Fax:423-892-5838
Practice Address - Street 1:303 PARKWAY DRIVE, NE
Practice Address - Street 2:BOX 404
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1212
Practice Address - Country:US
Practice Address - Phone:404-265-4520
Practice Address - Fax:404-265-3894
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004924367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1982637419OtherGROUP NPI
GAN357715OtherWELLCARE MEDICAID
GAP00418118OtherRAILROAD MEDICARE
GA1487726501OtherNPI
GA868831893AMedicaid
GA32BBBXGMedicare PIN