Provider Demographics
NPI:1235141078
Name:EVERTSON, LESLIE CHANG (NP)
Entity type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:CHANG
Last Name:EVERTSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:LESLIE
Other - Middle Name:CHANG
Other - Last Name:MCNIEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3666 VALENCIA AVE
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-2223
Mailing Address - Country:US
Mailing Address - Phone:805-522-3666
Mailing Address - Fax:
Practice Address - Street 1:1245 16TH ST
Practice Address - Street 2:SUITE 208
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1235
Practice Address - Country:US
Practice Address - Phone:310-825-8253
Practice Address - Fax:310-319-4141
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16341363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1235141078Medicaid
CAQ76575Medicare UPIN
CAGM013ZMedicare PIN
CAWNP16341AMedicare ID - Type Unspecified