Provider Demographics
NPI:1861590804
Name:WITHERSPOON, LESETTE D (PA-C)
Entity type:Individual
Prefix:MS
First Name:LESETTE
Middle Name:D
Last Name:WITHERSPOON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:401 W 220TH ST UNIT 43
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-2865
Mailing Address - Country:US
Mailing Address - Phone:310-324-5777
Mailing Address - Fax:310-324-6245
Practice Address - Street 1:19401 S VERMONT AVE
Practice Address - Street 2:BLDG L-100
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-1029
Practice Address - Country:US
Practice Address - Phone:310-324-5777
Practice Address - Fax:310-324-6245
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA11614363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical