Provider Demographics
NPI:1508887050
Name:ANDERSON, LESLIE N (PA-C)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:N
Last Name:ANDERSON
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 1:825 EASTLAKE AVE E
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98109-4405
Mailing Address - Country:US
Mailing Address - Phone:206-288-6952
Mailing Address - Fax:206-288-1435
Practice Address - Street 1:1959 NE PACIFIC ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-0001
Practice Address - Country:US
Practice Address - Phone:206-288-6952
Practice Address - Fax:206-288-2042
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003637363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA57635UOtherREGENCE BLUESHIELD
WA0189879OtherLABOR & INDUSTRY
WA8399172Medicaid
WA8399172Medicaid
WA57635UOtherREGENCE BLUESHIELD