Healthcare Provider Details

I. General information

NPI: 1427032812
Provider Name (Legal Business Name): LESLIE GULLAHORN OLSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LESLIE JOAN GULLAHORN

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 12/08/2023
Certification Date: 12/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2823 FRESNO ST
FRESNO CA
93721-1324
US

IV. Provider business mailing address

2625 E DIVISADERO ST
FRESNO CA
93721-1431
US

V. Phone/Fax

Practice location:
  • Phone: 559-459-4004
  • Fax: 559-459-5029
Mailing address:
  • Phone: 559-443-2682
  • Fax: 559-443-2681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number24897
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD482935
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberA76986
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA76986
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA76986
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: