MEDICARE: LESLEE EVERETT PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant		AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PT2018-045	OTHER	AR	MEDICAL LICENSE

General Provider Information

NPI Number	:	1881160240
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLEE EVERETT PA

Provider Business Mailing Address
First Line	:	4000 LINWOOD DR STE I
Second Line	:
City	:	PARAGOULD
State	:	AR
Zip	:	72450-7224
Country	:	US
Telephone Number	:	870-239-8102
Fax Number	:	870-239-8105

Provider Business Practice Location Address
First Line	:	1507 LINWOOD DR STE A
Second Line	:
City	:	PARAGOULD
State	:	AR
Zip	:	72450-5818
Country	:	US
Telephone Number	:	870-335-8063
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2018
Last Update Date	:	10/24/2019

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Directions to “ LESLEE EVERETT PA” Practice Location

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