Provider Demographics
NPI:1417967035
Name:IVERSON, LESLIE K (PA)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:K
Last Name:IVERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:4337 S BUTTERNUT RD
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-3621
Mailing Address - Country:US
Mailing Address - Phone:480-570-4922
Mailing Address - Fax:
Practice Address - Street 1:7410 S CREEK RD STE 100
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84093-6151
Practice Address - Country:US
Practice Address - Phone:801-816-1010
Practice Address - Fax:801-515-0045
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2023-01-13
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q62235Medicare UPIN
Z107707Medicare ID - Type Unspecified