Individual
LESLIE JEAN MCGOVERN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C, MHE, ATC, LAT
Contact information
Practice address
777 HOSPITAL WAY, POCATELLO, ID 83201-5175
(480) 421-9700
(480) 421-9899
Mailing address
PO BOX 15070, SCOTTSDALE, AZ 85267-5070
(480) 421-9700
(480) 421-9899
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
—
—
363AM0700X
Medical Physician Assistant
Primary
PA868
ID
363AS0400X
Surgical Physician Assistant
PA868
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1831184712
—
ID
01
—
P00902985
RAILROAD MEDICARE
—
Enumeration date
09/15/2005
Last updated
07/19/2011
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