Provider Demographics
NPI:1558809095
Name:RUDOLPH, LESLIE LIM (PA-C)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:LIM
Last Name:RUDOLPH
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 7469
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92615-7469
Mailing Address - Country:US
Mailing Address - Phone:714-962-1586
Mailing Address - Fax:714-962-1586
Practice Address - Street 1:1525 SUPERIOR AVE
Practice Address - Street 2:SUITE 214
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3639
Practice Address - Country:US
Practice Address - Phone:949-722-7902
Practice Address - Fax:949-722-7903
Is Sole Proprietor?:No
Enumeration Date:2017-02-04
Last Update Date:2017-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14530363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical