Provider Demographics
NPI:1831147313
Name:HALVORSON, LESLI L (PA-C)
Entity Type:Individual
Prefix:
First Name:LESLI
Middle Name:L
Last Name:HALVORSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LESLI
Other - Middle Name:L
Other - Last Name:OVERSTREET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:604 OAKESDALE AVE SW STE 102
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-5204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:604 OAKESDALE AVE SW STE 102
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-5204
Practice Address - Country:US
Practice Address - Phone:360-544-0837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003213363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P51975Medicare UPIN