Provider Demographics
NPI:1881098937
Name:SUDDUTH, LESLEY (MHS, PA-C)
Entity type:Individual
Prefix:
First Name:LESLEY
Middle Name:
Last Name:SUDDUTH
Suffix:
Gender:F
Credentials:MHS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6280 JACKSON DR STE 8
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92119-3436
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6280 JACKSON DR STE 8
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92119-3436
Practice Address - Country:US
Practice Address - Phone:619-464-1608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-17
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51871363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant