Individual
LESLEY S DISHAW
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PAC
Contact information
Practice address
1010 OLIVE AVE, FLORENCE, WI 54121-0380
(800) 380-7411
(715) 528-5592
Mailing address
PO BOX 22487, GREEN BAY, WI 54305-2487
(920) 445-7226
(920) 445-7229
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
1236023
WI
363A00000X
Physician Assistant
Primary
5601003358
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0852210330
BCBS MI
MI
05
—
41927000
—
WI
01
—
970028140
RR MEDICARE
MI
Enumeration date
11/15/2005
Last updated
09/30/2020
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