Healthcare Provider Details

I. General information

NPI: 1891896965
Provider Name (Legal Business Name): LESLIE ANN MAN-SEVERANCE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4601 DALE RD
MODESTO CA
95356-9718
US

IV. Provider business mailing address

2160 N MARION ST
DENVER CO
80205-5245
US

V. Phone/Fax

Practice location:
  • Phone: 209-557-1000
  • Fax:
Mailing address:
  • Phone: 414-217-1259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberG072244
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: