Provider Demographics
NPI:1174621676
Name:IVERSON, LESLIE D (ARNP, MPH)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:D
Last Name:IVERSON
Suffix:
Gender:F
Credentials:ARNP, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51377 SW OLD PORTLAND RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:SCAPPOOSE
Mailing Address - State:OR
Mailing Address - Zip Code:97056-4018
Mailing Address - Country:US
Mailing Address - Phone:503-418-4222
Mailing Address - Fax:503-418-4223
Practice Address - Street 1:51377 OLD PORTLAND ROAD
Practice Address - Street 2:SUITE C
Practice Address - City:SCAPPOOSE
Practice Address - State:OR
Practice Address - Zip Code:97056
Practice Address - Country:US
Practice Address - Phone:503-418-4222
Practice Address - Fax:503-418-4223
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200350038NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
R148822Medicare PIN