Provider Demographics
NPI:1043313133
Name:STOREY, LESLIE ANNE (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:ANNE
Last Name:STOREY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4388 N WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93704-3628
Mailing Address - Country:US
Mailing Address - Phone:559-476-0515
Mailing Address - Fax:
Practice Address - Street 1:7777 N. INGRAM AVE.
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-6281
Practice Address - Country:US
Practice Address - Phone:559-472-7546
Practice Address - Fax:559-385-7733
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81742207N00000X, 207NS0135X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI25537Medicare UPIN