Provider Demographics
NPI:1740248582
Name:SMITH, LESLEY JEANINE (PA)
Entity type:Individual
Prefix:
First Name:LESLEY
Middle Name:JEANINE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LESLEY
Other - Middle Name:JEANINE
Other - Last Name:BREWER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2488 E 81ST ST STE 290
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-4265
Mailing Address - Country:US
Mailing Address - Phone:918-927-3226
Mailing Address - Fax:918-927-3193
Practice Address - Street 1:2488 E 81ST ST STE 290
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-4265
Practice Address - Country:US
Practice Address - Phone:918-494-2665
Practice Address - Fax:918-927-3201
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK825363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100108200AMedicaid
OK970018308OtherRR MEDICARE
OK970018308OtherRR MEDICARE
OK100108200AMedicaid
OK243534801Medicare ID - Type Unspecified