Provider Demographics
NPI:1144395799
Name:DAVIS, LESLIE ANNETTE (PA)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:ANNETTE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11947 VALLEY VIEW ST UNIT 5671
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92846-6523
Mailing Address - Country:US
Mailing Address - Phone:562-246-6822
Mailing Address - Fax:562-330-2402
Practice Address - Street 1:3751 KATELLA AVE
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3113
Practice Address - Country:US
Practice Address - Phone:562-246-6822
Practice Address - Fax:562-330-2402
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16993363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB226038Medicare PIN