1467902932 NPI number — MS. LEISA CAROL LESEBERG AAS, RRT

Table of content: MS. LEISA CAROL LESEBERG AAS, RRT (NPI 1467902932)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467902932 NPI number — MS. LEISA CAROL LESEBERG AAS, RRT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LESEBERG
Provider First Name:
LEISA
Provider Middle Name:
CAROL
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
AAS, RRT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WOODS
Provider Other First Name:
LEISA
Provider Other Middle Name:
CAROL
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
AAS, RRT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1467902932
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5318 ANTELOPE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAR NUNN
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82601-9477
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-389-3355
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2360 E PERSHING BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHEYENNE
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82001-5356
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-778-7344
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/09/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 227900000X , with the licence number:  47 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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