Basic Information
| Provider Information | |||||||||
| NPI: | 1790068989 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 61 PROSPECT ST | ||||||||
| Address2: | APARTMENT B | ||||||||
| City: | PARAMUS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076524301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163138673 | ||||||||
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| Practice Location | |||||||||
| Address1: | 45 CROSSWAYS PARK DR W | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117972037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5169924568 | ||||||||
| FaxNumber: | 5169924637 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2011 | ||||||||
| LastUpdateDate: | 11/17/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 25MP00258200 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.