Provider Demographics
NPI:1699150375
Name:LESLIE, COURTNEY M (PA-C)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:M
Last Name:LESLIE
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 1:3455 LOCKE AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-5747
Mailing Address - Country:US
Mailing Address - Phone:817-529-6200
Mailing Address - Fax:817-529-6206
Practice Address - Street 1:3455 LOCKE AVE STE 210
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-5747
Practice Address - Country:US
Practice Address - Phone:817-529-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-23
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
TXPA10028363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant