Provider Demographics
NPI:1679920565
Name:TOLLIVER, LESLIE II (PA-C)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:TOLLIVER
Suffix:II
Gender:M
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 1:2101 E 74TH AVE # 12C
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-2776
Mailing Address - Country:US
Mailing Address - Phone:907-351-8401
Mailing Address - Fax:
Practice Address - Street 1:4100 LAKE OTIS PKWY
Practice Address - Street 2:SUITE 206
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5229
Practice Address - Country:US
Practice Address - Phone:907-929-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-20
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical