MEDICARE: MS. LESLINE RENA ANDERSON 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	PA 1175	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PA 1175	OTHER	CA	GENERAL

General Provider Information

NPI Number	:	1639337421
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LESLINE RENA ANDERSON PA

Provider Business Mailing Address
First Line	:	14718 HAWTHORNE BLVD
Second Line	:
City	:	LAWNDALE
State	:	CA
Zip	:	90260-1523
Country	:	US
Telephone Number	:	310-676-5673
Fax Number	:	310-679-5673

Provider Business Practice Location Address
First Line	:	14718 HAWTHORNE BLVD
Second Line	:
City	:	LAWNDALE
State	:	CA
Zip	:	90260-1523
Country	:	US
Telephone Number	:	310-676-5673
Fax Number	:	310-679-5673

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

Provider Enumeration Date	:	05/28/2008
Last Update Date	:	05/28/2008

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