Individual
LESLIE IRENE BURNSIDE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
147 W CHUBBUCK RD, CHUBBUCK, ID 83202-2314
(208) 238-7546
(208) 237-9643
Mailing address
147 W CHUBBUCK RD, CHUBBUCK, ID 83202-2314
(208) 238-7546
(208) 237-9643
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
PA-645
AL
363A00000X
Physician Assistant
Primary
PA518
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010152873
REGENCE BLUE SHIELD
ID
05
—
807303300
—
ID
01
—
PAA34
BLUE CROSS
ID
Enumeration date
03/15/2006
Last updated
07/22/2014
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