Provider Demographics
NPI:1639337421
Name:ANDERSON, LESLINE RENA (PA)
Entity Type:Individual
Prefix:MS
First Name:LESLINE
Middle Name:RENA
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14718 HAWTHORNE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWNDALE
Mailing Address - State:CA
Mailing Address - Zip Code:90260-1523
Mailing Address - Country:US
Mailing Address - Phone:310-676-5673
Mailing Address - Fax:310-679-5673
Practice Address - Street 1:14718 HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:LAWNDALE
Practice Address - State:CA
Practice Address - Zip Code:90260-1523
Practice Address - Country:US
Practice Address - Phone:310-676-5673
Practice Address - Fax:310-679-5673
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 1175363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA 1175OtherGENERAL