Provider Demographics
NPI:1508946286
Name:LESLIE-THEALL, CHERYL-ANN (PA)
Entity Type:Individual
Prefix:
First Name:CHERYL-ANN
Middle Name:
Last Name:LESLIE-THEALL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CHERYL-ANN
Other - Middle Name:
Other - Last Name:LESLIE-THEALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:2440 E TUDOR RD
Mailing Address - Street 2:SUITE 243
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-1185
Mailing Address - Country:US
Mailing Address - Phone:907-360-9914
Mailing Address - Fax:
Practice Address - Street 1:953 CRAMER CT
Practice Address - Street 2:
Practice Address - City:NORTH BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-1216
Practice Address - Country:US
Practice Address - Phone:516-567-3891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9103798363A00000X
UT8612468-1206363A00000X
AK483363A00000X
TX10503363A00000X
LA301088363A00000X
CA52939363A00000X
WA10004650363A00000X
NY0072911363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant