Provider Demographics
NPI:1508956210
Name:BEVONI, LEISHA ANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:LEISHA
Middle Name:ANNE
Last Name:BEVONI
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:PO BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-7208
Mailing Address - Country:US
Mailing Address - Phone:469-291-3372
Mailing Address - Fax:
Practice Address - Street 1:8611 HILLCREST AVE STE 300
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75225-4232
Practice Address - Country:US
Practice Address - Phone:214-692-3100
Practice Address - Fax:214-692-3141
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2002-0001207RE0101X
NMPA20020001207RE0101X
TXPA03861363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM04257Medicaid
TX348200YKPWMedicare PIN
NMQ17074Medicare UPIN
NM600521029Medicare ID - Type UnspecifiedCOMPANY UPIN