Provider Demographics
NPI:1558384362
Name:MYERS, LESLIE J (PMHNP)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:J
Last Name:MYERS
Suffix:
Gender:F
Credentials:PMHNP
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 42510
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97242-0510
Mailing Address - Country:US
Mailing Address - Phone:503-963-1290
Mailing Address - Fax:503-230-1541
Practice Address - Street 1:16110 SW REGATTA LN
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-8942
Practice Address - Country:US
Practice Address - Phone:503-629-2131
Practice Address - Fax:503-617-9379
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR77-037810-C363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
R77784Medicare UPIN