Provider Demographics
NPI:1013330992
Name:SHLEEF, LARA (PA)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:SHLEEF
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 1:3101 N CENTRAL AVE STE 550
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2635
Mailing Address - Country:US
Mailing Address - Phone:602-230-7373
Mailing Address - Fax:602-682-7455
Practice Address - Street 1:750 E THUNDERBIRD RD STE 1-3
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-5306
Practice Address - Country:US
Practice Address - Phone:602-682-7455
Practice Address - Fax:602-218-6383
Is Sole Proprietor?:No
Enumeration Date:2014-01-28
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5535364SP0808X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ212943Medicaid
AZ5535OtherAZ STATE LICENSE NUMBER
AZ212943Medicaid