Basic Information
| Provider Information | |||||||||
| NPI: | 1013330992 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHLEEF | ||||||||
| FirstName: | LARA | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3620 N 3RD ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022307373 | ||||||||
| FaxNumber: | 6026827455 | ||||||||
| Practice Location | |||||||||
| Address1: | 750 E THUNDERBIRD RD STE 1-3 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850225306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026827455 | ||||||||
| FaxNumber: | 6022186383 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2014 | ||||||||
| LastUpdateDate: | 03/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5535 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 212943 | 05 | AZ | MEDICAID | 5535 | 01 | AZ | AZ STATE LICENSE NUMBER | OTHER |