Provider Demographics
NPI:1881160240
Name:EVERETT, LESLEE (PA)
Entity type:Individual
Prefix:
First Name:LESLEE
Middle Name:
Last Name:EVERETT
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 1:4000 LINWOOD DR STE I
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-7224
Mailing Address - Country:US
Mailing Address - Phone:870-239-8102
Mailing Address - Fax:870-239-8105
Practice Address - Street 1:1507 LINWOOD DR STE A
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-5818
Practice Address - Country:US
Practice Address - Phone:870-335-8063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARPT2018-045OtherMEDICAL LICENSE