Healthcare Provider Details

I. General information

NPI: 1083328900
Provider Name (Legal Business Name): LESLIE MAGEE HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2023
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 E SUNBRIDGE DR STE 2
FAYETTEVILLE AR
72703-2857
US

IV. Provider business mailing address

61 E SUNBRIDGE DR STE 2
FAYETTEVILLE AR
72703-2857
US

V. Phone/Fax

Practice location:
  • Phone: 479-443-2210
  • Fax: 479-587-9455
Mailing address:
  • Phone: 479-443-2210
  • Fax: 479-587-9455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number673
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: