Provider Demographics
NPI:1477743136
Name:LUCERO, LESLEY (PA-C)
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:
Last Name:LUCERO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6815 NOBLE AVE
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-3796
Mailing Address - Country:US
Mailing Address - Phone:818-901-6600
Mailing Address - Fax:818-997-7826
Practice Address - Street 1:2400 BAHAMAS DR
Practice Address - Street 2:SUITE 200
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93309-0745
Practice Address - Country:US
Practice Address - Phone:661-328-5565
Practice Address - Fax:661-328-5573
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19222363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA19222Other19222 PA-LICENSE
CA19222OtherMP1608150-DEA