Basic Information
Provider Information | |||||||||
NPI: | 1487726501 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PETOSA | ||||||||
FirstName: | LESLIE | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PAAA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DEAN | ||||||||
OtherFirstName: | LESLIE | ||||||||
OtherMiddleName: | M | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PAAA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 932925 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 311932925 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8003649216 | ||||||||
FaxNumber: | 4238925838 | ||||||||
Practice Location | |||||||||
Address1: | 303 PARKWAY DRIVE, NE | ||||||||
Address2: | BOX 404 | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303121212 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4042654520 | ||||||||
FaxNumber: | 4042653894 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/14/2006 | ||||||||
LastUpdateDate: | 07/17/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 004924 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 1982637419 | 01 | GA | GROUP NPI | OTHER | N357715 | 01 | GA | WELLCARE MEDICAID | OTHER | P00418118 | 01 | GA | RAILROAD MEDICARE | OTHER | 1487726501 | 01 | GA | NPI | OTHER | 868831893A | 05 | GA |   | MEDICAID |