Provider Demographics
NPI:1598929101
Name:HUDDLESTON, LESLIE DIANE (PA-C)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:DIANE
Last Name:HUDDLESTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:HUDDLESTON
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 222
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-0222
Mailing Address - Country:US
Mailing Address - Phone:808-499-9979
Mailing Address - Fax:861-844-2469
Practice Address - Street 1:1478 AKIALOA PL
Practice Address - Street 2:
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-4274
Practice Address - Country:US
Practice Address - Phone:088-499-9979
Practice Address - Fax:844-861-2469
Is Sole Proprietor?:No
Enumeration Date:2008-07-13
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAMD-285363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical