Provider Demographics
NPI:1841267622
Name:BUCHANAN, LESLIE (PA)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:BUCHANAN
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 1:2925 SYCAMORE DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-1207
Mailing Address - Country:US
Mailing Address - Phone:805-578-9620
Mailing Address - Fax:805-955-0498
Practice Address - Street 1:2925 SYCAMORE DR
Practice Address - Street 2:SUITE 204-205
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1207
Practice Address - Country:US
Practice Address - Phone:805-578-9620
Practice Address - Fax:805-955-0498
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA12305363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS61653Medicare UPIN
CAWPA12305CMedicare ID - Type UnspecifiedPPIN #