Provider Demographics
NPI:1053458976
Name:POWELL, LESLIE T (PA)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:T
Last Name:POWELL
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-3727
Mailing Address - Fax:239-343-2086
Practice Address - Street 1:2780 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-5858
Practice Address - Country:US
Practice Address - Phone:239-343-3727
Practice Address - Fax:239-343-2086
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001777363AM0700X
FLPA9116235363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1053458976Medicaid
FL120707600Medicaid